The BlueBook - German Doctors eV

Transcription

The BlueBook
The Medical Guide for our Projects
th
2
nd
7 edition 2011
English edition 2011
Bettina Ritz
Co-Authors:
Lisa Sous, Peter Krieg, Wolfgang Schafnitzl
© Ärzte für die Dritte Welt – German Doctors e.V.
Offenbacher Landstraße 224, D- 60599 Frankfurt/Germany
Phone: +49- (0) 69 - 707 997- 0
Fax: +49 - (0)69 - 707 997- 20
E-mail: aerzte3welt@aerzte3welt.de
Thanks
This book could not have been written without the ideas and inspiration of
colleagues and friends. The authors would like to give thanks to all of them.
Special thanks go to Dr Marie Coen for her medical input and for the support
during our meetings in Hamburg, to Dr Barbara Hünten-Kirsch for help with
the chapter on HIV, Dr Heino Hügel for help with the chapter on
dermatological problems, Dr Elisabeth Kitzinger for help with the chapter on
diabetes mellitus, Dr Gunter Meyer for help with the chapter on epilepsy, Dr
Jobst Knief for help with the chapter on antenatal and postnatal care, Dr Sarah
Schwertz for help with the chapter on hyper- and hypothyrodism and Dr
Marion Reimer for help with the chapter on emergencies and for compiling the
list for the emergency kit.
We would also like to give thanks to Dr Barbara Schmidt who is working in
England and who was the first to read the book and check for mistakes with
spelling and English expressions, Dr Brigitte Huth and Dr Marion Reimer for
reading the book before it went to print.
Bettina also wants to give heartfelt thanks to family and friends for their
support and continued love and friendship in spite of the phrase “sorry I
haven´t got time - I am working on the BlueBook”.
The authors
Preface to the 7th edition
The sixth edition of the BlueBook was published 10 years ago. The version which
had originally been written for the project on Mindanao was adapted for the rest of
our worldwide projects, and the entire handbook was thoroughly revised. Since
that time, numerous physicians on many medical missions, but most of all our
patients, have profited from the BlueBook. More than 2,500 doctors have treated
patients who are so poor that they could not afford to see a doctor without our
help in 5,200 medical missions since 1983. The BlueBook has repeatedly been
praised by these German doctors in their mission reports and privately for its
extreme usefulness in the field and precise and comprehensible compilation of the
most important disease entities, diagnostic methods, and therapies.
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Contents
A lot has, however, changed or been further developed over the past ten years.
New medical knowledge has come to light, and new therapeutic possibilities have
become available. Our projects have also progressed – I only need remind you of
our comprehensive tuberculosis programs in Calcutta and the Philippines or our
continually growing HIV program in Nairobi, which did not even exist in this form
ten years ago. The conditions surrounding our projects have, of course, also
changed.
All these developments have made the necessity of a revision of the BlueBook
increasingly evident over the last few years. It is relatively easy to revise
something which is insufficient and achieve a positive result. It is, however, far
more difficult to up-date and even improve something which was originally created
with the utmost care and has already proven its worth. We are most grateful to the
editorial group consisting of Wolfgang Schafnitzl, Peter Krieg, and Lisa Sous and
led by Bettina Ritz, who undertook this responsible task and completed it with
such an excellent result. They donated many hours of their valuable (leisure) time
and expended tremendous effort on high-quality content and detailed linguistic
accuracy. They also received great support from the German doctors. We extend
our heartfelt thanks to all these authors and supporters.
The new revised edition of the BlueBook should serve as a guideline in respect to
the above-mentioned changed working conditions and possibilities available at
our various project sites. It should help to provide the best possible standard
treatment for our patients. It should also help guarantee the sustainability of the
work of the Doctors for Developing Countries. If we want to continue as a
humanitarian aid organization for people in the so-called third world, we have to
use our limited resources (donations) as efficiently as possible for the benefit of
our patients. One fundamental consideration which is often openly stated or at
least a constant background reminder in our guidelines in this new edition is that
costly diagnostic tests which have no consequences must be avoided. I sincerely
hope that this fundamental principle will always be taken seriously during our work
so that we can continue our projects for a long time and to the utmost benefit of
our target groups. The new BlueBook provides a good foundation for this purpose.
In conclusion, I would like to request everyone to continue sending supplementary
material, corrections, and suggestions for improvement which we can take into
consideration in future revisions.
Frankfurt, February 2011
Dr Harald Kischlat
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Contents
CONTENTS
Contents ............................................................................................ 4
1.
Binding Medical Guidelines ................................................. 10
2.
Psychological Aspects ......................................................... 20
3.
Clinical Presentations........................................................... 21
3.1. Cough ................................................................................................... 21
3.2. Dyspnoea.............................................................................................. 23
3.3. Fatigue .................................................................................................. 25
3.4. Fever..................................................................................................... 27
3.5. Nausea and Vomiting ........................................................................... 29
3.6. Anaemia................................................................................................ 31
3.6.1. Iron deficiency anaemia ..................................................................... 32
3.6.2. Thalassaemia .................................................................................... 34
3.6.3. Sickle cell anaemia ............................................................................ 35
3.6.4. Glucose-6-phospate dehydrogenase (G6PD) deficiency .................. 35
3.7. Jaundice ............................................................................................... 36
3.8. Seizures ................................................................................................ 38
3.9. Oral Diseases and Dental Problems..................................................... 39
3.9.1. Acute apical abscess ......................................................................... 40
3.9.2. Extradental manifestations of dental causes ..................................... 40
3.10. Emergencies ....................................................................................... 41
3.10.1. Loss of consciousness (LOC) .......................................................... 41
3.10.2. Severe chest pain ............................................................................ 42
3.10.3. Trauma ............................................................................................ 43
3.10.4. Aspiration of foreign body ................................................................ 44
3.10.5. Anaphylaxis/anaphylactic shock ...................................................... 45
3.10.6. Snake bite ........................................................................................ 47
3.10.7. Rehydration ..................................................................................... 47
4.
Respiratory Problems ........................................................... 49
4.1. Acute Respiratory Infections (ARI) ....................................................... 49
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Contents
4.1.1. Upper respiratory tract infection (URTI; common cold) ..................... 50
4.1.2. Lower respiratory tract infection (LRTI) ............................................. 50
4.1.2.1. Bronchitis ........................................................................................ 50
4.1.2.2. Pneumonia...................................................................................... 51
4.3. Acute Laryngo-Tracheobronchitis (Croup)............................................ 52
4.4. Acute Epiglottitis ................................................................................... 53
4.5. Obstructive Airways Disease ................................................................ 55
4.5.1. Bronchial asthma ............................................................................... 57
4.5.2. Chronic obstructive pulmonary disease (COPD) ............................... 63
4.6. Tuberculosis ......................................................................................... 65
4.6.1. Pulmonary tuberculosis ..................................................................... 65
4.6.2. Extrapulmonary tuberculosis ............................................................. 66
4.6.3. Tuberculosis in children ..................................................................... 67
4.6.4. Tuberculosis and AIDS ...................................................................... 69
5.
Gastrointestinal Problems.................................................... 71
5.1. Gastritis................................................................................................. 71
5.2. Hepatitis ................................................................................................ 73
5.2.1. Hepatitis A ......................................................................................... 73
5.2.2. Hepatitis B ......................................................................................... 73
5.2.3. Hepatitis C ......................................................................................... 73
5.2.4. Hepatitis D ......................................................................................... 74
5.2.5. Hepatitis E ......................................................................................... 74
5.3. Diarrhoea .............................................................................................. 75
5.3.1. Diarrhoea with fever and blood .......................................................... 76
5.3.1.1. Shigellosis....................................................................................... 76
5.3.1.2. Campylobacter enterocolitis ........................................................... 78
5.3.2. Diarrhoea with fever, without blood ................................................... 79
5.3.2.1. Salmonella enteritis ........................................................................ 79
5.3.2.2. Typhoid fever .................................................................................. 80
5.3.2.3. Extraintestinal infections in children................................................ 82
5.3.3. Diarrhoea without fever, with blood ................................................... 82
5.3.3.1. Amoebiasis ..................................................................................... 82
5.3.4. Diarrhoea without fever, without blood .............................................. 84
5.3.4.1. Traveller’s diarrhoea ....................................................................... 84
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Contents
5.3.4.2. Cholera ........................................................................................... 85
5.3.4.3. Giardiasis ........................................................................................ 85
5.4. Dehydration .......................................................................................... 89
6.
Malnutrition and Micronutrient Deficiencies ...................... 94
6.1. Malnutrition ........................................................................................... 94
6.2. Micronutrient Deficiencies..................................................................... 98
6.2.1. Vitamin D deficiency (rickets, osteomalacia) ..................................... 98
6.2.1.1. Rickets ............................................................................................ 98
6.2.1.2. Osteomalacia .................................................................................. 99
6.2.2. Vitamin A deficiency ........................................................................ 100
6.2.3. Iron deficiency.................................................................................. 101
7.
Parasitic Diseases............................................................... 102
7.1. Helminthiasis ...................................................................................... 102
7.1.1. Enterobius vermicularis (pinworm, threadworm) ............................. 102
7.1.2. Trichuris trichiura (whipworm).......................................................... 103
7.1.3. Ascaris lumbricoides (roundworm) .................................................. 104
7.1.4. Ancylostoma duodenale (hookworm) .............................................. 106
7.1.5. Strongyloides stercoralis (threadworm) ........................................... 108
7.1.6. Taenia saginata, taenia solium (tapeworm)..................................... 110
7.1.7. Schistosomiasis ............................................................................... 111
7.2. Filariasis.............................................................................................. 114
7.3. Leishmaniasis ..................................................................................... 117
7.4. Malaria ................................................................................................ 118
8.
Infectious Diseases............................................................. 125
8.1. Dengue Fever Syndromes .................................................................. 125
8.1.1. Dengue fever ................................................................................... 125
8.1.2. Dengue haemorrhagic fever (DHF), dengue shock syndrome (DSS)126
8.2. Leprosy ............................................................................................... 127
8.3. Measles (Morbilli)................................................................................ 128
8.4. Meningitis............................................................................................ 130
8.5. Pertussis (Whooping Cough) .............................................................. 133
8.6. Rabies................................................................................................. 134
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Contents
9.
Diseases of the Urinary Tract............................................. 138
9.1. Urinary Tract Infection ........................................................................ 138
9.2. Acute Glomerulonephritis ................................................................... 139
9.3. Nephrotic Syndrome ........................................................................... 140
10.
Sexually Transmitted Diseases/HIV................................... 142
10.1. Sexually Transmitted Diseases (STD) .............................................. 142
10.1.1. Gonorrhoea.................................................................................... 142
10.1.2. Chlamydial infection....................................................................... 143
10.1.3. Syphilis .......................................................................................... 144
10.1.3.1. Primary syphilis........................................................................... 144
10.1.3.2. Secondary syphilis ...................................................................... 145
10.1.3.3. Tertiary syphilis ........................................................................... 145
10.1.3.4. Congenital syphilis ...................................................................... 146
10.1.4. Chancroid (soft sore) ..................................................................... 146
10.1.5. Lymphogranuloma venereum (LGV) ............................................. 147
10.1.6. Trichomoniasis............................................................................... 147
10.1.7. Vulvovaginal candidiasis................................................................ 148
10.1.8. Genital herpes ............................................................................... 148
10.2. HIV .................................................................................................... 154
11.
Antenatal/Postnatal Care.................................................... 162
11.1. Antenatal Checks.............................................................................. 162
11.2. Ectopic Pregnancy ............................................................................ 164
11.3. Pre-Eclampsia .................................................................................. 165
11.4. Antepartum/Postpartum Haemorrhage ............................................. 167
11.4.1. Antepartum haemorrhage .............................................................. 167
11.4.2. Postpartum haemorrhage .............................................................. 168
11.5. Mastitis.............................................................................................. 169
12.
Skin Problems ..................................................................... 170
12.1. Skin Rashes...................................................................................... 170
12.1.1. Allergic rashes ............................................................................... 170
12.2. Dermatitis/Eczema............................................................................ 171
12.2.1. Allergic contact dermatitis .............................................................. 171
12.2.2. Irritant contact dermatitis ............................................................... 171
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Contents
12.3. Atopic Eczema .................................................................................. 172
12.4. Bacterial Infections ........................................................................... 173
12.4.1. Impetigo ......................................................................................... 173
12.4.2. Abscess ......................................................................................... 174
12.4.3. Erysipelas/cellulitis......................................................................... 175
12.4.3.1. Erysipelas ................................................................................... 175
12.4.3.2. Cellulitis ...................................................................................... 176
12.4.5 Tropical ulcer .................................................................................. 177
12.5. Fungal Infections .............................................................................. 178
12.5.1 Tinea (ringworm)............................................................................. 178
12.5.2 Candidiasis (thrush) ........................................................................ 180
12.5.3. Pityriasis (tinea) versicolor ............................................................. 181
12.6. Infestation of the Skin ....................................................................... 181
12.6.1. Scabies (seven year itch) .............................................................. 181
12.6.2. Pediculosis (louse infestation) ....................................................... 183
12.7. Burns ................................................................................................ 184
12.8. Wounds............................................................................................. 187
13.
Ophthalmological Problems............................................... 188
13.1. Cataract ............................................................................................ 188
13.2. Conjunctivitis..................................................................................... 188
13.3. Pterygium.......................................................................................... 190
13.4. Trachoma.......................................................................................... 191
14.
ENT Problems...................................................................... 194
14.1. Otitis Externa .................................................................................... 194
14.2. Otitis Media ....................................................................................... 194
14.3. Cerumen ........................................................................................... 196
14.4. Rhinitis/Sinusitis................................................................................ 196
14.5. Acute Tonsillitis ................................................................................. 197
15.
Different Other Conditions ................................................. 198
15.1. Endocrinological Problems ............................................................... 198
15.1.1. Goitre ............................................................................................. 198
15.1.1.1. Iodine deficiency ......................................................................... 198
15.1.1.2. Hypothyroidism ........................................................................... 199
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Contents
15.1.1.3. Hyperthyroidism .......................................................................... 199
15.1.2. Diabetes mellitus ........................................................................... 203
15.2. Epilepsy ............................................................................................ 206
15.3. Hypertension..................................................................................... 214
15.4. Coronary Heart Disease ................................................................... 216
15.5. Stroke (Cerebro-Vascular Accident) ................................................. 219
16.
Immunizations ..................................................................... 221
17.
List of Drugs ........................................................................ 223
17.1. Binding Drug List for all Outpatient Projects ..................................... 223
17.2. Important Medicines and their Dosages ........................................... 228
17.3. Emergency Kit .................................................................................. 232
17.3.1. Emergency drugs........................................................................... 232
17.3.2. Emergency equipment................................................................... 237
17.4. Drugs during Pregnancy and Breastfeeding ..................................... 238
18.
Abbreviations ...................................................................... 242
19.
Dictionary German – English ............................................. 246
20.
Bibliography ........................................................................ 255
21.
Index ..................................................................................... 258
9
Binding Medical Guidelines
1. BINDING MEDICAL GUIDELINES
These guidelines and notes were compiled by a group of 11 of our experts
who worked for several months in different projects of the committee.
The guidelines were updated in 2010.
They are binding for our projects.
Our principal aim is providing of humanitarian aid for people who cannot afford
medical treatment themselves. Our projects are situated in areas with
crowding, poverty and poor educational standard. It is therefore very important
for us to reach as many patients as possible, not a small group of patients
only.
A. PREPARATION OF CONSULTATION
1. General Facts
Every patient attending our clinics must be seen by the doctor if possible. The
health workers should not make decisions without consulting the doctor. Only
with great numbers of patients attending triage can be done by an
experienced health worker.
The patients have to be aware of our consulting hours.
It is possible to use numbers or stamps for queuing patients – not to limit the
number of patients attending but to establish a certain order. We want to avoid
that patients are jumping the queue.
If not all the patients can be seen the same day the doctor and the health
worker have to screen them for serious illnesses one hour before the end of
consultation.
2. Reception
Prior to consultation a health worker writes the complete patient data on the
patient card and weighs the patient.
10
Temperature and immunization status must be checked in both children and
infants. The weight must be written on the Road to Health Chart.
3. Documentation
Normally every patient card gets a cover and is to be taken home by the
patient. A small fee is to be paid for the first card. We can reduce the price for
needy patients or families with many children.
Every lost card must be paid for.
3.1. Road to Health Chart
In every project Road to Health Charts will be used for children under five. An
example can be found in the project folder.
It is very important to fill the Road to Health Chart correctly so that the child’s
progress can be monitored appropriately. That way, problems can be
recognized and treated early. The doctor checks the documentation every
time the child attends the clinic.
3.2. Patient Card
Adults receive a normal patient card.
Documentation must be done in standardized form according to the SOAPscheme.
S
O
A
P
symptoms
observations
assessment
plan
subjective complaints
objective findings
diagnosis
investigations, treatment
For better documentation these letters should be used and written down
clearly on the patient card with the individual entries. Each doctor should sign
the entry with his/her forename.
Permanent diagnosis should be highlighted and, if possible, added to the
patient data.
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Correct and clear documentation with recording of the permanent diagnosis
plays an important role in a successful treatment of patients.
4. Patient Education
Waiting patients must be educated daily by our health workers before or
during clinics. Topics should include treatment of simple infections or
diarrhoea, hygiene, prevention of parasitic infections, family planning, and
immunizations. It is important for the health worker to use teaching aids like
posters or flannel charts or other visual aids e.g. sugar, salt, water, and litre
bottle to prepare a sugar salt solution for the prevention of dehydration.
The doctor has to make sure that teaching takes place on a regular base and
should motivate the health workers accordingly.
5. Training of Health Workers
We regard the training of our health workers as highly important. Therefore it
should be done at least once a week by doctors and should cover topics
relevant for work.
Long term doctors/project coordinators organize a training schedule and
discuss the time and topics. Each colleague is asked to participate.
A list of teaching aids like colour slides, PowerPoint presentations or books
(“Where there is no doctor”) is available in the projects. Topics from own
specialities can be introduced. Additional topics can be chosen covering
recent problems, but should take into account the diseases of the area we are
working in.
6. Working Hours
We work 8 hours 5 days a week. We should not start later than 8.30 am. We
have to remind the staff to start on time. There are no afternoons off.
Journeys to and from work are not part of the working hours of our staff.
Included is travelling with the “Rolling Clinic”. We should finish on time as
some members of our staff have quite a long journey home and a family to
look after.
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7. Social Screening
Social screening is always difficult for us. Very poor people come with
borrowed (rather good) clothes to the foreign doctor so that they do not loose
face and look poor. Social screening can only be done by our local staff. There
are questionnaires in the projects which can be used on a home visit to
assess whether the patient is in need.
Social screening is always necessary if there is going to be expensive
treatment of acute illnesses, operations or treatment of chronic conditions.
B. MEDICAL ACTIVITY
Every project has a specific range of diseases and available diagnostic and
therapeutic facilities. Therefore we find a folder in each project with
information applying to the local situation only (together with the binding
medical guidelines).
Every doctor is obliged to read the project information and binding guidelines
prior to working in the field and to follow them closely.
1. Available Diagnostic Procedures and their Limitations
Making a correct diagnosis is the basis of successful medical treatment. As we
are working in resource poor countries we have to rely on good history taking
and thorough clinical examination.
We always have to consider the therapeutic consequences especially as there
is a wide range of diagnostic procedures and therapeutic options available in
most countries we work in.
We should order diagnostic investigations only if the resulting treatment can
be paid for by the committee at a reasonable price.
To use our own resources as efficiently as possible we have to observe the
following rules:
13
CT-scans can be ordered, but in limited numbers only. They should preferably
be discussed with the coordinator or at least with colleagues in the project.
It is always possible to ask the medical coordinator in Frankfurt.
MRI-scans must always be discussed with the committee in Frankfurt. They
must have affordable therapeutic consequences.
Ultrasound scans should be used as diagnostic procedures if there is an
ultrasound machine in the project. Otherwise it is possible to order an
ultrasound scan at a local institution. Films are only necessary if
requested specifically by a hospital or a local specialist.
Endoscopies are to be ordered only with severe illness and affordable
therapeutic consequences. They must be discussed with the project
coordinator.
Echocardiographies should be performed by colleagues if possible. Specialists
should only be involved if there are affordable therapeutic consequences.
Laboratory investigations should be used sparingly. Screening investigations
are not allowed. Specific investigations e.g. tumor markers, Hbelectrophoresis or CRP are often not necessary.
HIV-tests can be ordered if special counselling before and after the test is
available.
Hepatitis serology is often not necessary as there are no therapeutic
consequences.
Stool investigations should only be performed in patients with symptoms not
responding to therapy.
If possible we must use state-run health services which are free of charge.
2. Treatment of Disease and its Limitations
Our aim is to provide basic medical treatment in resource poor countries. This
includes treatment of acute conditions which can be cured within a reasonably
short period of time and treatment of certain chronic conditions. Infectious
diseases requiring long term treatment are included in special programs.
14
2.1. Chronic Conditions – Long Term Treatment
We treat chronic disease if the patient is indigent, compliant with the therapy
and if patient education is available. Patients who repeatedly do not turn up for
their medication in time are not treated by us.
2.1.1. Diabetes Mellitus
Counselling about diet and weight loss are the most important aspects of
diabetes therapy in our projects. Patients with diabetes type II can also be
treated with tablets. Patients with diabetes type I are only treated if they are
well educated about their illness and can be followed up regularly in a diabetic
clinic or by a coordinator.
2.1.2. Hypertension
Hypertension should only be treated if repeated readings have shown severely
raised blood pressure.
2.1.3. Bronchial Asthma/COPD
Prior to treating obstructive airways disease it is necessary to take a proper
history and educate patients thoroughly. Inhalers must not be prescribed
unless the patient can use them properly. If possible the patient should attend
an asthma clinic.
2.1.4. Thyroid Disease
Hypothyroidism and hyperthyroidism are treated with medication after an
appropriate blood test. Patients with goitre compressing the trachea can be
referred to a local hospital.
2.2. Tuberculosis
Tuberculosis has a high prevalence in resource poor countries. Spread of the
disease and development of resistant bacilli can only be prevented by
consequent long term therapy. Therefore most projects have their own
tuberculosis program or refer to a state-run program.
15
2.3. Leprosy
Patients with leprosy need long term treatment. Therefore they are referred to
state-run programs for diagnosis and treatment.
2.4. HIV-related Diseases
HIV-related diseases can only by treated symptomatically by us. Antiviral
treatment after counselling is only possible in a special HIV-project in Nairobi.
Medication for post-exposure prophylaxis is available for our doctors in high
risk areas like Nairobi and Kolkata.
2.5. Malignancies
Operations for tumors with good prognosis can be paid for by the committee.
A treatment plan and estimate of the costs must be discussed beforehand with
the coordinator in Frankfurt. The committee does not pay for radiotherapy or
chemotherapy.
2.6. Poor Eyesight
Eye glasses are only financed by us if the vision is very limited and the patient
has problems in daily life or his/her job. The patient should always be asked
for a small contribution.
3. Drugs
Our aim is to treat a wide range of diseases appropriately and cost-effectively.
We treat patients according to the guidelines of the World Health
Organization.
To achieve a continuity of medical care we adhere strictly to the binding drug
list (see appendix) and the treatment recommendations in the BlueBook.
Drugs not on this list can only be given for one week in rare cases. The first
time medication for long term treatment should be supplied for two weeks
only. With good adjustment and compliance long term medication can be
16
dispensed for four weeks. Long term medication in the “Rolling Clinic” must be
adjusted according to the schedule.
Prescription of vitamin tablets should be restricted to special indications like all
medication. They should not be used as placebo.
Herbal medicine can be a useful addition to drug treatment and should be
used where possible. Physiotherapy for chronic pain can be given in the field
and should be encouraged by us.
For routine treatment only medicines on the binding drug list are allowed in
our projects.
They can be brought from Germany.
Disposable material like gloves, urine or glucose sticks, venflons, sofratuell or
oleotuell are always welcome. It is recommended to speak with the
coordinator in the project beforehand.
4. Disposal of Waste
Each doctor should make sure that used needles are cut with the needle
cutter and disposed of in unbreakable and puncture-resistant containers.
Infectious waste should be burnt.
5. Emergencies
For emergency medical treatment an emergency bag is available for every
team. It must be taken out in the field and be checked and looked after by
each doctor on a regular base. A checklist is found in every emergency bag.
This bag is for emergencies only. Drugs must not be taken out for every day
use.
6. Home Visits
Home visits are a useful tool to get to know the living conditions of our
patients. They should only be done together with the local staff, in Ocotal and
Nairobi only during the day.
17
7. Cooperation with Hospitals
As a rule we refer patients to state-run hospitals. Here they receive medical
treatment free of charge; drugs and diagnostic procedures must be paid for.
We can undertake to pay the costs for needy patients but we need an
estimate – except in emergencies. A health worker should accompany the
patients to guarantee their admission in hospital.
We can refer patients for further diagnostic procedures to state-run outpatient
clinics. The committee pays for diagnostic investigations and treatment after
thorough checking of the planned procedures.
Because of the expensive treatment patients should be referred to private
hospitals only in rare cases. Each admission should be discussed with the
project coordinator beforehand.
8. Additional Programs
8.1. Additional Feeds
In our projects there are feeding programs for different groups of patients.
Under- and malnourished children must be admitted to a feeding ward where
they get the necessary food and the mothers receive help with feeding and
education e.g. about breastfeeding and healthy nutrition.
Undernourished Tb- and HIV-patients can be sent to our feeding program –
where available – offering one warm meal daily.
In some of the projects needy families can receive basic food on a regular
base. When putting families on the program the doctor should listen to the
advice of the local staff.
8.2. Family Planning
In our projects female patients can receive contraception typical for the area. It
is always necessary to get the husband to agree to it.
18
During consultation the local staff should be encouraged to talk about family
planning. As foreigners we should avoid giving recommendations.
8.3. Antenatal Care
We have to give special attention to the counselling and careful check-ups of
pregnant women. In the projects we have special forms and guidelines which
should be observed closely.
8.4. Immunization Programs
Immunizations are vital in improving child health. Therefore it is important to
check the immunization status of every child coming for consultation.
With missing documentation or incomplete immunization status we should
advise the immunizations recommended by the World Health Organization
(BCG, DPT, Polio, measles, hepatitis B). Where possible we should make
sure that the children are immunized straight away.
8.5. Partner Projects
Partner projects help with financing treatment of certain diseases (e.g.
treatment of Tb in Kolkata). They provide money from third parties without any
costs for the committee.
Private initiatives must be discussed with the medical coordinator in Frankfurt.
We must not organize treatment for patients outside their respective home
countries.
19
Psychological Aspects
2. PSYCHOLOGICAL ASPECTS
Working in our projects we have to bear in mind that living conditions of many
th
of our patients are similar to those in Germany during the 19 century: high
birth rates, high infant mortality, low life expectancy, diseases of poverty
caused by malnutrition, contaminated drinking water, unsanitary and crowded
living conditions.
Therefore we have to take into consideration that e.g.
• the mother complaining about weakness and dizziness may not know how
to feed her children after her husband left her.
• the malnourished man with pulmonary tuberculosis complaining about
upper epigastric pain may just be hungry.
• the mother whose child died two weeks ago may present with headache.
• the 10-year old girl may have back pain because she has to carry heavy
buckets of water to earn her living.
• the mother suffering from insomnia may be afraid of getting pregnant as
she had severe bleeding during her last delivery and nearly died of it.
With the sheer number of patients it is often not possible to address these
problems. Nevertheless we should
• try and address the underlying problem – patients are grateful for our
understanding and empathy.
• avoid giving multivitamins and painkillers just in order to give something.
• counsel regarding hot compresses, massages, sufficient fluid intake.
We do not give antidepressant or antipsychotic medication. If treatment is
needed we should refer patients to a native doctor who knows the cultural
background and is therefore better qualified to treat patients appropriately.
20
Clinical Presentations
3. CLINICAL PRESENTATIONS
3.1. Cough
•
•
•
Physiological method of clearing the airways
Persistent cough: may be caused by underlying disease or disorder
Often associated with dyspnoea (see chapter Dyspnoea, p.23)
Questions to ask:
Cough productive (with phlegm) or dry?
Colour of sputum (purulent, haemoptysis)?
Duration of symptoms (acute: cough for up to 3 weeks or chronic:
cough > 3 weeks)?
Onset (sudden onset, progressive)?
Exposure to air pollutants (e.g. smoke of fire)?
Smoker?
Any pre-existing disease?
Concurrent medication (ß-blockers, ACE-inhibitors)?
Association with other symptoms and signs (weight loss, fever, loss of
appetite, dyspnoea, psychological signs)?
Clinical examination:
Nutritional status (weight, ?anaemia)
Temperature
Cardiovascular system (heart, lung, blood pressure)
Gastrointestinal system (abdomen, spleen, liver)
Lymph nodes
Mucus membranes (?cyanosis)
Investigations as necessary:
FBC
AFB
Peak flow
CXR
21
⚖ Differential diagnosis:
22
Acute cough:
ο Diseases of the airways:
> URTI, tracheobronchitis (?viral infection)
> Sinusitis (?postnasal drip)
> Whooping cough (?bouts of cough associated with vomiting)
> Croup (?inspiratory stridor)
> Aspiration (?sudden onset, often distress)
> Exposure to air pollutants (?history)
> Bronchial asthma (?recurrent episodes, nocturnal attacks)
> Parasitic disease (?loss of appetite, history of worms)
ο Diseases of the lungs:
> Pneumonia (?fever, dyspnoea, productive sputum)
> Pleurisy (?pleuritic pain)
> Pulmonary embolism (?sudden onset, period of immobility,
pregnancy)
> Pneumothorax (?sudden onset, accident)
ο Heart diseases:
> Acute left ventricular failure (cardiac asthma: ?history of
chestpain, crackles on auscultation)
Chronic cough:
ο Diseases of airways and lungs:
> Bronchial asthma (?recurrent episodes of cough, nocturnal
symptoms)
> COPD (?smoker)
> Malignant disease (?anorexia, haemoptysis)
> Lung disease e.g. bronchiectasis, interstitial lung disease
> Reactive Airways Dysfunction Syndrome (?exposure to pollutants)
ο Infectious disease:
> Tuberculosis (?weight loss, night sweats, haemoptysis)
> Whooping cough (?bouts of cough associated with vomiting)
ο Extrapulmonary diseases:
> Gastrointestinal reflux (GORD ?burning retrosternal pain)
> Side effect of medication
> Chronic left ventricular failure (?history of heart disease,
crackles on auscultation, peripheral oedema with RVF)
> Malignancies e.g. lymphoma (?anorexia)
Note:
Always think of aspiration of foreign body in young children (< 5 years of age)
who present with sudden onset of cough (especially if there is distress or no
improvement under therapy).
3.2. Dyspnoea
•
•
Causes: physiological (e.g. with blockage of airways, reduced blood
supply with insufficient oxygenation of body and brain) or psychological in
nature
4 stages depending on the symptoms:
I.
II.
III.
IV.
•
•
no dyspnoea (no limitation of physical activity)
dyspnoea on strenuous exertion (slight limitation of
physical activity)
dyspnoea on slight exertion (marked limitation of
physical activity, comfortable at rest)
dyspnoea at rest (unable to carry out physical activity
without discomfort)
Often associated with cough (see chapter Cough, p.21)
Subjective symptom, therefore it is very important to take a detailed history
Questions to ask:
Acute or chronic?
Sudden onset or slow progression?
Recurrent episodes?
Aggravating factors (e.g. worse on lying down, nocturnal dyspnoea)?
Association with other symptoms or signs (weight loss, fever, cough
and sputum, cyanosis, psychological signs)?
Pre-existing diseases (e.g. pulmonary disease, heart disease, atopic
disposition)?
Nutritional status (weight, ?anaemia)
23
Temperature
Neurological status
Lymph nodes
Mucus membranes (?cyanosis)
Psychological status
AFB
FBC
Peak flow
CXR
24
Diseases of airways/lungs:
ο Laryngitis, croup, aspiration (?fever, inspiratory stridor, ?acute
with aspiration)
ο Bronchial asthma (?recurrent episodes, nocturnal attacks, acute
onset)
ο COPD/emphysema (?exposure to environmental pollutants, smoker)
ο Pneumonia (?fever, sputum)
ο Tuberculosis (?weight loss, haemoptysis, night sweats)
ο Whooping cough (?bouts of cough associated with vomiting)
ο Malignant disease (?anorexia, haemoptysis)
ο Pneumothorax (?sudden onset, pain)
ο Fibrosis/pneumoconiosis (?slow onset, history of farming or
working in dusty environment e.g. coal dust, asbestos, silica dust)
ο Pleural effusion (?pleuritic pain, fever)
Diseases of the cardiovascular system:
ο Congestive cardiac failure: CCF (?pulmonary oedema, peripheral
oedema)
ο Myocardial infarction (?severe pain and distress, sudden onset)
ο Arrhythmias, valvular heart disease, myocarditis (?irregular pulse,
cardiac murmur, history of severe tonsillitis)
ο Pericarditis (?pain, relieved by sitting forward, pericardial rub,
heart failure with pericardial tamponade)
ο Pulmonary embolism (?sudden onset, period of immobility, pregnancy)
Miscellaneous diseases:
ο Anaemia (?pallor, pregnancy, worms)
ο Pregnancy
ο Fever
ο Obesity
ο Gross ascites (?history of bloody diarrhoea, jaundice)
ο Hyperthyroidism, retrosternal goiter (?exophthalmos, diarrhoea,
tachycardia)
ο Inhalation of toxins (?history)
ο Neurological disorder (?weakness, muscle wasting, ataxia)
ο Lack of exercise
Psychological illness:
ο Hyperventilation (?difficulty sleeping, sadness worse in the morning, difficulty thinking and concentrating, apathy, history of
traumatic event in the past e.g. death of child)
3.3. Fatigue
•
•
•
•
Very common complaint during consultation
Often described as lack of energy, weakness, tired all the time
Mainly psychological in nature, but organic illness must be taken into consideration.
Subjective symptom – therefore it is very important to take a detailed history.
Questions to ask:
Duration of symptoms (recent, prolonged, chronic)?
Onset (sudden, progressive)?
Recovery period (short, long)?
Type of fatigue (physical, mental, sexual)?
Time of fatigue (morning, evening)?
Concurrent medication (antidepressants, ß-blocker, antihistamines)?
Alcohol or drug abuse?
Association with other symptoms or clinical signs (weight loss, fever,
loss of appetite, psychological signs)
Pregnancy?
25
Nutritional status (weight, ?signs of anaemia or vitamin deficiency)
Temperature
Lymph nodes
Mucus membranes, skin
Psychological status
Urinalysis
Creatinine
Blood sugar
FBC
AFB
CXR
26
Viral illness (?history of gastroenteritis, severe cold)
Anaemia (?pallor, malnutrition, pregnancy, menorrhagia)
Parasite infections (?anaemia, abdominal pain, worms, hepatosplenomegaly)
Heart failure (?dyspnoea, murmur, crackles on auscultation)
Asthma/COPD (?dyspnoea, wheezing, nocturnal symptoms)
Tuberculosis (?cough, haemoptysis)
Diabetes mellitus (?polyuria, polydipsia)
Malignant disease (?melaena, haemoptysis, anorexia, fever, recurrent
infections, lymphadenopathy)
Hepatitis (?jaundice)
Psychological illness (?difficulty sleeping, sadness worse in the morning, difficulty thinking and concentrating, apathy, history of traumatic
life event e.g. death of child)
Neurological disorder (?weakness, muscle wasting, visual defects,
ataxia)
Note:
Very often fatigue is a reaction to living under difficult conditions (e.g. heavy
work, lack of money, insufficient food) or traumatic events like severe illness
or death in the family. Being able to talk to someone who listens can be very
helpful.
3.4. Fever
•
•
•
•
Definition: axillary temperature > 37.0° C in the morning, 38.0° C in the
evening; rectal > 37.5° C in the morning, > 38.5° C in the evening
Common in children, therefore it is very important to take a detailed
history.
Complications of fever in the newborn/infant: convulsions, dehydration,
malignant hyperthermia with collapse, coma
Always consider multiple causes of fever.
Nutritional status (weight, signs of anaemia or vitamin deficiency)
Temperature
Ears, throat
Mucus membranes, skin, teeth
Neurological status
Lymph nodes
Consider investigations depending on history. They are not routine investigations!
Urinalysis
Blood sugar
Blood smear (malaria parasites)
FBC
AFB
27
Abdominal ultrasound
CXR
28
Acute:
ο Malaria (?endemic areas; high fever, chilling, headache)
ο Typhoid fever (high fever, slowly rising; headache, cough, constipation, relative bradycardia, abdominal pain, diarrhoea)
ο Meningitis, meningoencephalitis (?high fever, neck stiffness, neurological signs)
ο Septicaemia (?shock, toxaemia, jaundice)
ο Dengue fever (?haemorrhagical symptoms, rash)
ο Hepatitis (?jaundice, tender liver, dark urine)
ο Look for focal signs, e.g.:
> Tonsillitis (?lymphadenopathy, exudate on tonsils)
> Otitis (?fluid behind ear drum)
> Pneumonia, bronchiolitis (?crackles, wheezes)
> Dental abscess (?decayed teeth)
> Measles (?Koplik spots, rash)
> Cystitis, pyelonephritis (?dysuria, haematuria, proteinuria)
> Abscess, osteomyelitis (?painful swelling)
> Rheumatic fever (?joint pain, joint swelling, rash)
Prolonged fever (more than 2 weeks):
ο Tuberculosis (?low grade fever, haemoptysis, night-sweats)
ο Amoebic liver abscess (?hepatomegaly, nausea, vomiting)
ο Schistosoma
mansoni/haematobium/japonicum
infections
(?bloody diarrhoea, haematuria, hepatosplenomegaly)
ο Malaria (?endemic areas)
ο UTI (?dysuria, haematuria)
ο Filariasis (?lymphangitis of limbs, scrotum)
ο HIV infections (?anorexia, recurrent infections, AIDS-related
symptoms)
ο Collagenosis and others
Fever during the last month of pregnancy always think of:
ο Malaria
ο Pyelonephritis
Note:
With prolonged fever always consider that treatment might not be working
(e.g. because of resistant bacteria).
If possible always check urine in children with fever lasting longer than 24
hours!
3.5. Nausea and Vomiting
•
•
•
•
Protective reflexes of the body preventing the entry of toxins
Many organic causes but often psychological component
Most of the time self-limiting but with risk of dehydration attention should
be given early especially to young children and older patients.
Often associated with diarrhoea (see chapter Diarrhoea, p.75)
Questions to ask:
Acute or longer lasting?
Recurrent episodes?
Time (early morning)?
Aggravating factors (e.g. worse with or after food)?
Associated with pain?
Concurrent medication (NSAIDs, antibiotics, opioids, theophylline,
digoxin)?
History of alcohol or drug abuse?
Smoking?
Pregnancy?
Association with other symptoms and signs (?lethargy, weight loss,
haematemesis, melaena, faecal vomit, vertigo, psychological signs)?
Pre-existing diseases (e.g. diabetes mellitus, migraine, malignancy,
gallstones, heart disease, asthma/COPD, renal problems)?
29
Note:
To assess degree of dehydration in a child it is very important to ask the
mother about decrease in urination or thirst and assess the condition (?alert,
lethargic), eyes (?sunken), skin turgor (?dry) and fontanelle (in infants,
?sunken).
General condition (?lethargic)
Mucus membranes, skin (?dry)
Nutritional status (weight, ?signs of anaemia)
Temperature
Neurological status (neck, eyes, strength, reflexes)
Psychological state
Urinalysis
Creatinine
Blood sugar
FBC
30
Abdominal disorders:
ο Gastroenteritis (viral, parasitic; ?with diarrhoea, ?other people
affected)
ο Peptic ulcer disease (?vomiting during eating, nocturnal pain, pain
relieved with eating and antacids)
ο Gastroesophageal reflux (?burning retrosternal pain)
ο Acute abdominal emergencies e.g. appendicitis, perforated ulcer,
ectopic pregnancy (?fever, severe abdominal pain, occasionally
sudden onset, getting worse, rigid abdomen)
ο Intestinal obstruction (?faecal vomit, distended rigid abdomen,
hyperactive bowel sounds or loss of bowel sounds)
ο Cholecystitis (?pain right upper abdomen, esp. with fatty food)
ο Hepatitis (?jaundice)
ο Pancreatitis (?fever, severe central abdominal pain)
ο Malignant disease (?anorexia, abdominal mass)
Central nervous disorders:
ο Migraine (?recurrent episodes, headaches, aura, visual disturbance)
ο Vertigo, labyrinthitis (?symptoms worse on moving, nystagmus)
ο Meningitis, encephalitis (?fever, severe headache, neck-stiffness,
rash)
ο Increased intracranial pressure e.g. with malignancy, hydrocephalus (?history, neurological deficits)
Metabolic disorders:
ο Diabetic ketoacidosis (?history of diabetes, dehydration, hyperventilation, acidosis)
ο Uraemia (?pallor, oedema, hypertension)
Pregnancy
ο Morning sickness (?missed periods)
ο Hyperemesis gravidarum
Adverse effects of drugs
Toxins
ο Food poisoning (?other people affected, associated with diarrhoea)
ο Alcohol abuse (?early morning vomit)
ο Medication, drug abuse (?history)
Psychiatric causes:
ο Functional dyspepsia (?recurrent multiple unrelated complaints,
history of traumatic life events)
3.6. Anaemia
•
•
•
Decreased level of haemoglobin (below the reference levels for age, sex
and pregnancy; e.g. males: < 12 g/100 mL; females < 11 g/100 mL), due
to impaired production of red cells, loss of red cells due to bleeding or
increased destruction (haemolysis)
Major causes: malnutrition (iron and/or folate deficiency, mainly in children
or women of childbearing age), infections (e.g. malaria, helminth
infections, tuberculosis or HIV/AIDS), bleeding (e.g. ulcer)
Rarer causes: sickle cell disease, thalassaemia, leishmaniasis and others
31
✎ Diagnosis:
Regarding diagnostic procedures: always think of cost-effectiveness and
therapeutic consequences! They should only be performed if previous
treatment had been unsuccessful (e.g. for hookworms).
Look for diagnostic signs e.g. splenomegaly, hepatomegaly (?malaria,
kala-azar, schistosomiasis, sickle cell anaemia, thalassaemia), fever
(?malaria), haemoptysis (?tuberculosis), haematemesis (?peptic ulcer
disease), blood in faeces.
Laboratory investigations:
ο Haemoglobin, haematocrit
ο Blood film to check red cell morphology, target cells etc.
Questions to ask to interpret blood results:
ο Is the anaemia hypochromic (e.g. iron deficiency anaemia) or
normochromic (check MCHC)?
ο If hypochromic are there target cells (thalassaemia)?
ο If normochromic is the anaemia normocytic or macrocytic (check
MCV)?
ο If normocytic could it be due to blood loss or haemolysis (consider
thick film for malaria)?
ο If macrocytic is the anaemia megaloblastic (folate or vitamin B12
deficiency)?
3.6.1. Iron deficiency anaemia
There are 2 categories of iron in the diet:
• Heme iron: in meat, poultry, fish; easily absorbed
• Nonheme iron: in vegetables e.g. legumes, pumpkin, beans, peas;
also in cereals, wheat, barley, oat etc.; not easily absorbed
(absorption of iron is enhanced by ascorbic acid and inhibited by
tannates in tea and coffee)
• Highest prevalence: children of the age of 6 months to 3 years and
women of childbearing age due to menstruation or pregnancy
Clinical manifestations:
32
Weakness, fatigue
Dizziness, tachycardia
Pallor, headache
Failure to thrive in children
Dyspnoea
In severe cases: congestive cardiac failure
Occasionally pica (eating of dirt containing iron compounds)
Laboratory findings:
Reduced MCV (≤ 70 – 75 fl) and MCHC (microcytic, hypochromic)
Treatment (WHO and INACG guidelines) recommendations:
Elementary iron:
ο Children: 5 mg/kg od
ο Adults: 120 mg od
ο Duration of treatment: 3 months; children under 2 years: up to 24
months of age
Inform patients about possible side effects e.g. dark stools, stomach
upsets, constipation etc.
Prophylaxis:
Pregnant women:
ο Elementary iron: 60 mg od plus folic acid 0.8 mcg od until delivery
Malnourished children:
ο Elementary iron: 2 mg/kg/day plus folic acid 5 mg od; after 1
weeks:
ο Elementary iron: 2 mg/kg/day for 4 weeks
ο Severely malnourished children: iron supplement should not be
given during the first days of treatment
Note:
Dosage must be adjusted to available preparations e.g. ferrous sulphate:
elementary iron: 3 : 1.
Anthelmintic treatment:
ο Albendazole:
> Children < 2 years: 200 mg single dose
> Children > 2 years, adults: 400 mg single dose (avoid in the
first trimester of pregnancy)
33
ο
Mebendazole:
> Children > 2 years, adults: 100 mg bid for 3 days (avoid in the
first trimester of pregnancy)
Blood transfusion: must be restricted to severe anaemia (danger of transmitting
diseases such as hepatitis B or C, HIV, malaria, syphilis etc.); use relatives as
blood donors if at all possible.
☂
Prevention:
Nutritional advice: eat foods rich in iron such as meat, fish, chicken,
liver; also dark leafed vegetables like peas, lentils, with fruit rich in
ascorbic acid such as papaya, mango, pineapple, sweet potato.
Avoid drinking tea and coffee or diary products with main meals.
Advice regarding cleanliness
Advice regarding spacing of children
3.6.2. Thalassaemia
•
•
Reduced production of globin chains leading to ineffective erythopoesis
and haemolysis with subsequent anaemia
Mainly in the Mediterranean and South East Asia
Major form:
ο Starting in infancy
ο Hypochromic microcytic anaemia with target cells
ο Children: failure to thrive
ο Recurrent infections, splenomegaly
ο Early death due to severe anaemia
Minor form:
ο Usually asymptomatic
ο Mild anaemia, worse during pregnancy
Treatment:
Folic acid only:
ο Children < 1 year: 0.5 mg/kg od
ο Children > 1 year, adults: 5 mg od
ο Duration of treatment: up to 4 months
34
Avoid treatment with iron (danger of haemosiderosis)
Major form: problem with transfusion - > life-long treatment, therefore
not possible in our projects
3.6.3. Sickle cell anaemia
•
•
•
Severe haemolytic anaemia due to production of abnormal haemoglobin
Common in black Africans
Different degrees of haemolysis according to severity of illness
Normocytic anaemia with reticulocytosis, sickle cells and target cells
in blood film
Jaundice
Often: painful swelling of hands and feet
Splenomegaly in children
Later: renal failure, bone necrosis, infections
Sickle cell crisis:
ο Thrombotic crisis brought on by infection, dehydration etc.
ο Severe pain, often in the bones
ο DD: acute abdomen, pneumonia
Treatment:
Folic acid:
ο Children > 1 year, adults: 5 mg/day
ο Duration of treatment: up to 4 months
Transfusion:
ο Only if absolutely necessary (with signs of decompensation e.g.
cardiac failure)
ο Packed red blood cells or blood from relatives if at all possible
Sickle cell crisis:
ο Analgesics e.g. paracetamol or tramadol
3.6.4. Glucose-6-phospate dehydrogenase (G6PD) deficiency
•
High prevalence in African, Asian and eastern European population
35
•
•
•
Linked to the x-chromosome: males and homozygous females mainly
affected
Enzyme defect conferring susceptibility to developing haemolytic anaemia
with certain food (e.g. fava beans), drugs (e.g. primaquine or sulfonamides) or severe infections
Also conferring about 50% protection against severe malaria
Symptoms depending on the severity of enzyme deficiency
Symptoms developing rapidly:
ο Haemolytic anaemia
ο Jaundice
ο Dark urine (haemoglobinuria)
ο Pallor
Neonatal jaundice more severe with G6PD deficiency
Treatment:
No causative treatment available
Withdraw offending drug
Avoid causative agents
Note:
Always remember to do a screening test for glucose-6-phophate dehydrogenase deficiency before starting a patient on primaquine.
3.7. Jaundice
•
•
•
•
36
Yellow discolouration of skin, sclerae and mucosa due to raised bilirubin
levels
Three different origins: pre-hepatic, hepatocellular, post-hepatic
Common in the tropics
Often associated with liver disease
Questions to ask:
Age of patient (?neonate)?
Duration of symptoms (?long lasting, recurrent episodes)?
Concurrent medication (?paracetamol, barbiturates, methyldopa)?
Pregnancy?
Aggravating factors (e.g. worse after fatty food)?
Associated with other symptoms or clinical signs (?fever, itching,
scratch marks, palmar erythema, spider naevi, pale stools,
gynaecomastia, loss of body hair, hepatomegaly, ascites, oedema,
muscle wasting)?
Pre-existing diseases (e.g. gallstones, malignancy, heart disease,
asthma/COPD, renal problems)?
General condition (?lethargic)
Nutritional status (weight, ?signs of anaemia)
Temperature
Skin
FBC
LFT
Blood smear
Pre-hepatic jaundice:
ο Haemolytic anaemia (?anaemia, splenomegaly, joint pains)
Hepatocellular jaundice:
ο Acute viral hepatitis (?fever, nausea, tender hepatomegaly,
splenomegaly, arthralgia)
ο Chronic hepatitis (?hepatosplenomegaly, spider naevi, fatigue)
ο Liver cirrhosis (?history of hepatitis, hepatic foetor, liver flap:
tremor worse by hand extension, ascites, haematemesis, encephalopathy)
ο Hepatocellular carcinoma
ο Alcoholic liver disease (?history)
ο Schistosomiasis
37
ο Toxic hepatitis due to medication or drugs (?history)
Posthepatic jaundice:
ο Biliary obstruction e.g. gallstones (?colicky pain)
ο Helminthiasis with ascaris (?worms)
ο Infection e.g. cholangitis, pancreatitis, abscess (?fever, ?high
blood sugar)
3.8. Seizures
•
•
•
•
Usually presenting as grand mal (tonic-clonic movement of all four limbs)
with loss of consciousness, occasionally with tongue bite and urinary
incontinence
General population: 8-10% lifetime risk of one seizure, 3% risk of epilepsy
Acute disturbance of the brain; can be provoked or unprovoked.
Carefully taken history is very important.
Questions to ask:
Any previous events?
Family history?
Any post-ictal symptoms?
Association with clinical signs e.g. fever?
Concurrent medication (theophylline, tramadol)?
Any coexisting illness?
Nutritional status (weight)
Temperature
Neurological status (pupils, reflexes, power, ?neck stiffness etc.)
Gastrointestinal system (abdomen, spleen, liver, uterus)
Psychological state
38
Febrile convulsion (?child, viral illness)
Meningitis/encephalitis (?fever, neck-stiffness; always to be considered in children aged 18 months to 6 years)
Hypoglycaemia (?medication, history of diabetes)
Eclampsia (?pregnancy)
Epilepsy (?aura, family history)
Brain injury/tumor/abscess (?neurological deficits)
Infectious disease (?malaria, tuberculosis, cysticercosis, schistosomiasis etc.)
Intracranial bleeding (?sudden onset of severe headache, trauma)
Excessive intake of alcohol or drugs/withdrawal (?history)
Medication
Severe psychological stress, sleep deprivation (?history)
Transient ischaemic attack/cerebro-vascular accident (stroke)
Cardiac arrhythmias (?irregular pulse, murmur)
Syncope
Complex migraine (?history of migraine, ?with symptoms e.g. visual
disturbance)
Metabolic encephalopathy (?suggestion of electrolyte disturbance e.g.
hypoglycaemia in rickets)
Note:
Always check the blood sugar in a patient presenting with epileptic fit or loss of
consciousness!
Refer patient to hospital urgently if meningitis or eclampsia is suspected!
3.9. Oral Diseases and Dental Problems
• Decayed teeth: common problem of patients attending consultation; mainly
request for painkillers
• Dental infections: possible cause of pyrexia of unknown origin, bacterial
endocarditis or abscess formation in different organs
39
Important to remember:
• Check teeth of patient and advise extraction of decayed teeth and root
segments if necessary.
• Give simple instructions on healthy nutrition and on dental hygiene e.g.
thorough cleaning and massage of the marginal gingival (“area where the
gum touches the tooth”).
3.9.1. Acute apical abscess
Severe pain and swelling around the root of the tooth
Fluctuation
Facial swelling
Complication: retropharyngeal abscess with airways obstruction
Treatment:
Refer for incision and drainage.
Antibiotics: Penicillin V: children: 30-60 mg in 3-4 divided doses,
adults: 500 mg qid
Analgesics: paracetamol or NSAID prn
3.9.2. Extradental manifestations of dental causes
Headache, pain over the sinuses, in the temporal area:
Possible cause: nonvital tooth in the upper jaw
Diagnosis: pain on percussion of affected tooth
Refer for extraction of tooth.
Headache, ear ache:
Possible cause: nonvital tooth in the lower jaw
Diagnosis: pain on percussion of affected tooth
Refer for extraction of tooth.
Stomach pain, difficulties with digestion:
Can be caused by inability to chew food properly due to loss of teeth.
40
Treatment:
Toothless patients should crush the food and move it in the mouth for
some time.
Patients with few teeth should use their teeth properly and take a lot of
time with their meals.
3.10. Emergencies
•
•
•
Due to limited resources emergency treatment should only be done on a
basic level.
Advanced treatment e.g. intubation is not indicated because of poor
outcome especially while working in remote areas.
It is our intention to stabilize the patient with basic means and organize
transport to the nearest hospital as soon as possible.
Note:
Make sure that the patient is put in the correct position, kept warm and as
calm and free of pain as possible.
Even if rushed it is nevertheless very important to take a proper history!
3.10.1. Loss of consciousness (LOC)
Questions to ask:
Time of LOC
History of pain, fever, trauma
Past medical history
History of medication, drug or alcohol abuse
?Breathing
?Pulse palpaple
Blood pressure (?hypotension)
Skin (?dry, clammy)
Temperature (?fever)
41
Pupils (?dilated, reacting to light)
Blood sugar (BM-stix ?hypoglycaemia)
?Reaction to pain
?Signs of anaemia
Metabolic disorder e.g. hypoglycaemia
Meningitis, cerebral malaria, cerebral schistosomiasis
Intoxication, drugs
Epilepsy, trauma
It is of utmost importance to check the blood sugar in an unconscious patient!
Treatment:
Recovery position
Tilt head back to open the airway.
Give oxygen if available.
Monitor pulse and blood pressure closely.
If possible take BM-stix:
ο Hypoglycaemia, history of diabetes and on diabetic medication
give:
> Adults: 20 mL of 40% glucose slowly IV
> Children: 5 mL/kg of 10% glucose slowly IV
Hypertensive crisis:
ο Give 1-2 puffs of GTN-spray SL to lower blood pressure carefully.
3.10.2. Severe chest pain
Myocardial infarction, pulmonary embolism, trauma
42
Distress
Dyspnoea
Pallor
Treatment:
Sit patient up.
GTN-spray 2 puffs stat SL if systolic BP > 100 mmHg
Put up IV line.
Aspirin 500 mg stat
If required:
ο Diazepam 5-10 mg IV
ο Tramadol 2 mg/kg IV or
ο Nalbuphine 0.2 mg/kg IV; maximum single dose in nonopioidtolerant patient: 20 mg; maximum daily dose: 160 mg
3.10.3. Trauma
Assess injuries of patient.
Remove from danger area.
Observe for loss of consciousness (LOC).
Check pulse and blood pressure.
Check chest (?signs of pneumothorax e.g. respiratory distress,
reduced breath sounds, reduced chest movements, paradoxical
breathing).
Put patient in appropriate position.
Treatment:
Undress and keep patient warm.
Position:
ο If conscious and shocked: raise legs.
ο LOC and breathing: recovery position
ο Breathing and conscious: position on back
ο If respiratory problems and conscious: sitting or half-sitting position if tolerated
ο If necessary: stabilize neck.
Bleeding wounds: apply pressure bandage.
Cover wounds with sterile dressing.
Splint injured limbs.
43
Large IV cannula (16 G in adults); if in shock give Ringer’s Lactate
solution 1-3 litres IV; if available give gelafundin 30-40 mL/kg IV.
Give analgesics e.g.
ο Tramadol IV, IO, IM, PO:
> Children 1-11 years: 1-2 mg/kg up to tid prn
> Children ≥ 12 years, adults: 2 mg/kg up to tid prn
ο Ketamine IV, IO:
> Adults, children: 0.25 – 0.5 – 1 mg/kg
ο Nalbuphine IV, IO, IM, SC:
> Adults, children: 0.2 mg/kg prn; maximum single dose in nonopioid-tolerant patient: 20 mg; maximum daily dose: 160 mg
3.10.4. Aspiration of foreign body
Sudden onset of cough, cyanosis
Stridor (inspiratory, exspiratory)
Paradoxical breathing
Treatment:
Check mouth and throat and remove any obvious obstruction.
Heimlich manoeuvre (abdominal thrust)
44
Heimlich manoeuvre (abdominal thrust):
Patient lying on the back: kneel astride the casualty, place heel of one
hand on abdomen between umbilicus and xiphoid and cover with the other
hand. Press sharply inwards upwards towards the chest up to five times
(imitating cough to expel the foreign body).
If the patient is upright stand behind the patient, place right fist below the
xiphoid, cover it with the left hand; pull sharply and quickly inwards and
upwards towards the chest.
Modified Heimlich manoeuvre for infants, children:
Infants, children < 1 year: lay infant on your forearm or thigh on the
stomach in head down position; give 5 blows on the back between the
shoulder blades with the heel of the hand. If obstruction persists turn child
and give 5 chest thrusts in the middle of the breast bone (in infants with 2
fingers, in older children with the heel of the hand). Continue until foreign
body is expelled.
Children > 1 year: give 5 blows to the back of the child sitting, kneeling or
lying on the stomach. If obstruction persists continue with abdominal
thrust (see adults).
3.10.5. Anaphylaxis/anaphylactic shock
•
•
•
•
Severe life-threatening, generalized or systemic hypersensitivity reaction
Can be associated with insect bites, certain food (e.g. eggs, fish, nuts,
esp. peanuts etc.).
Also associated with medical products, e.g. vaccines, antibiotics, blood
products, aspirin etc.
More likely after parenteral administration of medication
Erythema, urticaria
Hypotension, tachycardia
Bronchospasm, laryngospasm
Sudden onset and rapid progression of symptoms
45
Treatment:
Stop causative agent straight away.
Lie patient flat, raise feet; if unconscious: recovery position.
Give adrenalin 1 in 1000 (1mg/mL) straight away IM (anterolateral
thigh); also possible, but less effective: SC (do not waste time looking
for a vein where IM injection can be successful):
ο Adults:
0.5 mL (500 mcg)
ο Children:
0.01 mg/kg (= 0.01 mL/kg) or
> up to 6 years
0.15 mL (150 mcg)
> 6-12 years
0.3 mL (300 mcg)
> > 12 years
0.5 mL (500 mcg)
ο Can be repeated every 5 minutes according to pulse and blood
pressure.
In rare cases e.g. severely ill patients when adequate circulation may
not be maintained in the periphery adrenaline can also be given IV:
ο Adrenaline 1 : 10 000 (100 mcg/mL) IV:
> Adults: titrate 50 mcg (0.5 mL) boluses according to response
> Children: titrate 0.01 mg/kg (0.1 mL/kg) boluses according to
response.
ο After initial resuscitation give hydrocortisone:
> Adults: 2 mg/kg IM or slow IV up to qid prn
> Children 4-8 mg/kg stat. IM or slow IV, then 2 mg/kg up to qid
prn
ο Give antihistamines e.g.
> Diphenhydramine:
− Adults, children: 1-2 mg/kg slowly IV or IM
− Can be given up to tid prn
Note:
Treatment with antihistamines cannot replace treatment with adrenaline: they
do not relieve bronchoconstriction or shock; they are only effective for
urticaria and itching.
46
3.10.6. Snake bite
•
Should be suspected if a patient presents with severe pain, redness and
swelling of a limb or unexplained illness with severe pain, bleeding and
neurological problems.
Swelling of limb
Necrosis
Shock
Bleeding e.g. from gums
Neurological symptoms e.g. paralysis, difficulties in swallowing or
talking
Puncture marks may be visible.
Treatment:
Lay patient down, affected limb below heart level, apply firm bandage
to affected limb from toes or fingers to proximal site of bite; immobilize
with splint.
Put up IV infusion.
Urgent transport to hospital
Do not cut the wound, suck out the venom or apply a tourniquet.
3.10.7. Rehydration
See chapter Dehydration, p.89
Treatment for child in shock:
Give Ringer’s Lactate solution IV:
ο 20 mL/kg in the first hour, repeat if no improvement
ο 2.-4. hour: 12-15 mL/kg/h
ο From 5. hour: 6-10 mL/kg/h, reassess and speed up if patient
deteriorates.
47
Intraosseous infusion
•
•
•
•
•
•
•
•
•
•
48
Should only be used in an emergency if intravenous access is not
available within a short period of time.
Dosages and action of drugs and intravenous fluids comparable to IV
administration
Puncture site: antero-medial aspect of tibia, at the junction of upper and
medial third
Use intraosseous needle if available.
In young children: use of large-bore hypodermic needle or butterfly needle
possible.
Important: thorough disinfection of injection site
o
Insert needle at 90 angle to tibia, stop when decrease of resistance is felt
or aspiration of blood is possible.
Stabilize needle and secure with tape.
Check whether infusion is running correctly and there is no swelling of skin
surrounding the injection side or calf.
Insert IV-line as soon as possible and discontinue intraosseous infusion.
Respiratory Problems
4. RESPIRATORY PROBLEMS
4.1. Acute Respiratory Infections (ARI)
•
•
•
•
•
•
•
Divided into:
- upper respiratory tract infections (URTI, affecting nose, ears,
throat, pharynx and larynx) and
- lower respiratory tract infections (LRTI; affecting bronchi, bronchioli
or lungs)
Very common, esp. in infancy and childhood
Associated with poor housing, poor hygiene, inadequate food and clothing
Incidence of chronic respiratory diseases: rising due to air pollution in big
cities
High mortality with LRTI (20% of all the deaths in children under 5 years of
age)
High risk: low birth weight children, children under 5 years of age with low
immunization status, children and adults with anaemia and malnutrition or
concomitant diseases e.g. measles, pulmonary tuberculosis or HIV
Further risk factors: alcohol, diabetes
Taking a detailed history, examining the patient properly and making a
diagnosis (to differentiate between simple viral infection and severe
pneumonia) and starting adequate treatment are of utmost importance.
Questions to ask in children:
How is the child (?well, responding, sleepy, drinking or eating well)?
Increased respiratory rate?
Any wheeze?
Chest-wall retractions?
• Always consider otitis media or purulent tonsillitis (see chapter ENT
Problems, p.194)
Foreign body (?sudden onset)
Tuberculosis
Croup
Epiglottitis
Asthma/COPD
49
Parasitic lung infection (lung passage of ascaris, hookworm,
strongyloides (?worms, urticaria)
4.1.1. Upper respiratory tract infection (URTI; common cold)
Causative agents:
Mainly viruses e.g. respiratory syncytial virus (RSV) or adenovirus
Risk of bacterial superinfection e.g. with Haemophilus influenzae,
pneumococci, streptococci or Staphylococcus aureus
Cough, runny nose, sore throat
Occasionally raised temperature
Risk of infection spreading to lower respiratory tract
Treatment:
Increase fluid intake.
Encourage breastfeeding.
Antibiotics not necessary, but give if superinfected.
Saline nose drops for blocked nose (0.9% NaCl)
Paracetamol for pain or pyrexia
ο Children: 30 mg/kg in 3-4 divided doses
ο Adults: 500 mg qid
Fever: patient should be sponged down with lukewarm water.
4.1.2. Lower respiratory tract infection (LRTI)
4.1.2.1. Bronchitis
50
Fever, barking cough
Clear frothy sputum; can get purulent with secondary bacterial
infection.
Wheezy chest
Normal respiratory rate at rest:
ο Infants < 2 months: < 60/min
ο Children 2-11 months: < 50/min
ο
ο
Children 1-5 years: < 40/min
Children 6-8 years: < 30/min
If the respiratory rate is higher pneumonia is likely.
Treatment:
Antibiotics only indicated with yellow/ green sputum, persistent cough
or suspected pneumonia (see below); otherwise: see treatment for
URTI.
4.1.2.2. Pneumonia
Causative agents:
Pneumococci, Haemophilus influenzae, staphylococci, also: viruses,
Mycoplasma pneumoniae; with AIDS: also Pneumocystis carinii
Occasionally due to inhaled foreign body (history important – sudden
onset?)
Fever, tachycardia
Tachypnoea: respiratory rate: children < 2 months: > 60/min;
2-11 months: > 50/min; 1-2 years: > 40/min; 6-8 years > 30/min
Dyspnoea, chest-wall retractions, nasal flaring, cyanosis
In children: difficulty feeding
Treatment:
Do not wait for x-ray to confirm diagnosis.
Antibiotics indicated:
ο Amoxicillin:
> Children: 50 mg/kg in 3 divided doses
> Adults: 500-1000 mg tid or
ο Erythromycin:
> Adults: 500 mg qid
ο Duration of treatment: 7 days
Give oxygen if necessary.
51
Encourage breastfeeding.
Fever:
ο Take clothes off; sponge down with lukewarm water.
ο Paracetamol:
> Children: 30 mg/kg in 3-4 divided doses
> Give with temperature > 39° C.
ο Severe cases: refer to hospital for treatment.
ο Persistent symptoms: refer for sputum examination and/or x-ray to
exclude tuberculosis.
There is no indication for codeine or other cough suppressants.
☂
Prevention:
Advice regarding appropriate clothing
Advice regarding breastfeeding of children
Check immunization status of children and immunize as required after
recovery.
Advice regarding food, hygiene
4.3. Acute Laryngo-Tracheobronchitis (Croup)
•
•
Most common cause of upper respiratory obstruction
Mainly in children from 3 months to 5 years
Causative agents:
Mainly viruses (influenza, para-influenza, respiratory syncitial virus)
52
Initially mild symptoms, can get progressively worse.
Symptoms usually worse at night
ο Runny nose
ο Mild fever
ο Pharyngitis
Mild croup:
ο Hoarse voice
ο Barking cough
ο Inspiratory stridor when agitated
Severe croup:
ο Signs of severe illness: pallor, chest-wall retractions, nasal flaring,
increased respiratory rate
ο Stridor at rest
ο Tachypnoea
ο Cyanosis
ο Fatigue
Inhalation of foreign body
Retropharygeal abscess
Diphtheria
Acute epiglottitis
Treatment:
Mild croup:
ο Antipyretics e.g. paracetamol
ο Encourage oral fluids
ο Rest
Severe croup:
ο Keep the child in upright position.
ο Try to keep child calm.
ο Prednisolone PO 1-2 mg/kg od for 3 days
ο If available: nebulizer with adrenaline (0.5 mL/kg of 1 : 1000 solution up to 5 mL; may be repeated every hour if needed; important:
careful monitoring)
ο If no improvement admit to hospital for oxygen, observation,
intensive treatment.
4.4. Acute Epiglottitis
Causative agent:
Haemophilus influenzae
53
Sudden onset
High fever
Severe respiratory symptoms (dyspnoea, chest-wall retractions)
Child sitting up, drooling saliva
Treatment:
Do not try to examine the throat.
Keep child in upright position.
Admit to hospital straight away for treatment with antibiotics.
Intubation or tracheostomy will be needed with incipient airway
obstruction.
If admission is not possible give antibiotics e.g. chloramphenicol
100 mg/kg IM in 3 divided doses.
If airway obstruction and help not readily available coniotomy can be
life-saving.
Coniotomy:
Only to be done in dire emergencies!
•
•
•
•
or
•
•
54
After infiltration with lignocaine 1% cut skin underneath the larynx
1.5-2 cm lengthwise.
Take large-bore cannula connected to 5 mL syringe.
Insert at right angle to trachea between the two cartilages.
Aspirate air, withdraw the needle and ventilate (small volumes, high frequency).
Cut across the cricothyroid ligament.
Insert shortened gastric tube, suction tube or catheter.
4.5. Obstructive Airways Disease
Always think of differential diagnosis of asthma versus COPD (different
response to medication!).
Differential diagnosis of bronchial asthma versus COPD:
Bronchial Asthma
COPD
Age of first diagnosis
Onset in early
childhood)
life
(often
Cause
Hyperresponsiveness of airways; not caused by smoking
Exposure
to
smoke, fumes
Symptoms
Recurrent attacks; symptoms
often at night or early morning
Permanent dyspnoea on
exertion
Allergy
Often trigger factor; often
allergies, rhinitis and/or eczema present
Rarely trigger factor
Airways Obstruction
Recurrent attacks; fully reversible
Progression of obstruction, not fully reversible
Medication
Responding to inhaled corticosteroids
Only occasionally responding to inhaled corticosteroids
Onset in midlife
tobacco
It is of utmost importance that every patient with the diagnosis of asthma or
COPD is referred to an asthma clinic (when available in the projects). The
diagnosis must be written clearly on the patient chart.
✎ Diagnosis:
Asthma:
ο In our projects: at present only testing of peak expiratory flow
possible, measuring variability of airflow limitation; for children > 5
years and adults
55
>
Ideally measuring should be done in asthma clinics by trained
staff or by patients with good compliance at home (peak flow
chart).
> Measurements should ideally be taken with same peak flow
meter, preferably with the patient’s own peak flow meter,
always taking the best of 3 readings.
> Diagnosis should be based on patient’s previous best peak
flow (fully treated or asymptomatic, PEFR usually better in the
evenings than in the mornings) or of predicted value for age
and sex.
> Diurnal variability > 20% (10% with twice daily readings) of
peak flow measurements {(maximum - minimum PEFR)/
maximum PEF x 100 (%)} or improvement of 60 l/min (or
≥ 20% of pre-bronchodilator PEF) after inhalation of a
bronchodilator is suggestive of asthma.
> Poorly controlled asthma: PEFR < 60% of predicted or
personal best; diurnal variability often poor
ο Chest x-ray: seldom diagnostic but useful in excluding pulmonary
tuberculosis or cardiac failure
COPD:
ο Peak flow measurements: poor diurnal variability and little
improvement after inhaled bronchodilator despite symptoms
ο Chest x-ray: seldom diagnostic but useful in excluding pulmonary
tuberculosis or cardiac failure
56
Helminths (?history)
Pulmonary tuberculosis (history of haemoptysis, anorexia, night
sweats)
Gastrooesophageal reflux (?burning retrosternal pain)
Aspiration of foreign body (?sudden onset)
Congestive cardiac failure (?ankle oedema)
Vocal cord dysfunction
Hyperventilation, panic attacks
4.5.1. Bronchial asthma
•
•
•
Chronic inflammatory disorder of the airways with intermittent airway
obstruction due to bronchospasm, swelling of mucus membranes and
hypersecretion of mucus
Triggered by certain allergens (e.g. furred animals, cockroach allergens,
domestic mites, pollens, yeast, fungi), respiratory tract infections, exercise,
cold air, smoke or others
Often other members of the family with asthma or atopic eczema
Intermittent wheezing, tightness, dyspnoea
Recurrent cough (esp. in children, after exercise)
Nocturnal symptoms (cough, wheeze)
Severe attacks: chest-wall retractions (smaller children), severe
dyspnoea, cyanosis, silent chest on auscultation
Normal respiration in between the attacks
Often connected with atopic eczema
57
Levels of asthma control (after GINA 2010):
Characteristic
Controlled
(All of the
following)
Partly
controlled
(Any measure
present)
Daytime symptoms
None
(twice or
less/week)
More than
twice/week
Limitations of activities
None
Any
Nocturnal
symptoms/awakenings
None
Any
Need for reliever
None
(twice or
less/week)
More than
twice/week
Normal
< 80% of predicted or personal best (if
known)
Lung function (PEFR)
Uncontrolled
Three or more
features of
partly controlled
asthma
Assessment of future risk (risk of exacerbation, instability, rapid decline in lung
function, side effects)
58
Treatment:
Adjust treatment to best possible control.
If not controlled, consider stepping up to gain control.
Exacerbation: treat as such.
Reduction of treatment can be attempted after control has been maintained for at least 3 months.
Reliever medication: Salbutamol MDI prn (after teaching and with
good technique of patient; young children: best given with spacer e.g.
plastic cup or plastic bottle with hole in the bottom for inhaler)
Step 1:
ο Salbutamol metered dose inhaler (MDI): 1-2 puffs as required or
ο Salbutamol PO:
> Children 2-6 years: 0.3-0.6 mg/kg in 3 divided doses prn
(max. 4 mg tid)
> Children 6 -12 years: 2 mg prn up to qid
> Children > 12 years, adults: 2-4 mg prn up to qid
ο Terbutaline suspension PO: children: 0.2 mg/kg in 3 divided doses
prn
ο Problems with metered dose inhalers: compliance of patients
(more difficult to use – always make sure that patient knows how
to use the device!), more expensive than oral medication
Step 2:
ο Under supervision of an asthma clinic: add inhaled steroids (if
available; advantage: fewer side effects than oral medication) e.g.:
> Beclomethasone metered dose inhaler (MDI):
− Adults: 200 mcg bid
− Children: 50-100 mcg bid
ο If not available give salbutamol tablets PO:
> Children 2-6 years: 0.3-0.6 mg/kg in 3 divided doses (max.
4 mg tid)
> Children 6 -12 years: 2 mg tid-qid
> Children > 12 years, adults: 2-4 mg tid-qid
ο Terbutaline suspension: children 0.2 mg/kg in 3 divided doses
Step 3:
ο Increase inhaled steroids:
> Beclomethasone MDI:
− Adults: 400 mcg bid
− Children: 100-200 mcg bid
59
ο
With oral medication: add
> Aminophylline:
− Adults: 100-200 mg tid (10 mg/kg/day); avoid in children
Step 4:
ο With inhaled steroids add:
> Aminophylline PO:
− Adults: 100-200mg tid (10 mg/kg/day); avoid in children
ο Otherwise add:
> Prednisolone PO:
− Adults: lowest possible dose to control symptoms e.g.
5 mg od in the morning
− Children: 1 mg/kg od in the morning
− Reduce to lowest possible dose.
> Exclude tuberculosis before starting the patient on long term
steroid treatment.
Acute attack (emergency):
Progressive increase of
ο Dyspnoea
ο Cough, wheeze
ο Tightness of chest
Asthma attacks may be life-threatening.
60
Severity of Asthma exacerbations (after GINA 2010):
Parameter
Mild
Moderate
Severe
Walking
Can lie down
Talking
Infant: difficulty
feeding
Prefers sitting
At rest
Infant: stops
feeding
Hunched forward
Talks in
Sentences
Phrases
Words
Alertness
May be agitated
Usually agitated
Usually agitated
Respiratory rate
Increased
Increased
Often > 30/min
Wheeze
Moderate, often
only and expiratory
Loud
Usually loud
Pulse/min
< 100
100-120
> 120
60-80%
< 60% predicted or
personal best
(< 100 l/min
adults) or
response lasts < 2
hrs
Breathless
PEFR
After initial bronchodilator
% predicted or
% of personal best
> 80%
Normal respiratory rate in awake children:
< 2 months:
2-11 months:
1-5 years:
6-8 years:
< 60/min
< 50/min
< 40/min
< 30/min
Normal pulse rate in children:
2-12 months:
1-2 years:
2-8 years:
< 160/min
< 120/min
< 110/min
Respiratory arrest imminent:
ο Patient drowsy or confused
ο Absence of wheeze
61
ο
ο
Bradycardia
Paradoxical thoraco-abdominal movement
Treatment:
Salbutamol:
ο Inhaler (as effective as nebulizer):
> Start with 2-4 puffs every 20 minutes for the first hour.
> Then:
− Mild exacerbations: 2-4 puffs every 3-4 hours
− Moderate exacerbations: 6-10 puffs every 1-2 hours
> Best given with spacer e.g. plastic cup or plastic bottle with
hole in the bottom for inhaler.
ο Salbutamol via nebulizer (if available):
> Start with:
− Children ≤ 5 years: 2.5 mg every 20 minutes for the first
hour
− Children > 5 years, adults: 2.5-5 mg every 20 minutes for
the first hour
> Then repeat according to response (max. 40 mg daily).
ο Glucocorticosteroids:
> Prednisolone PO:
− Children: 1 mg/kg for 5 days, then stop if possible.
− Adults: 40 mg for 7 days, then stop if possible or
> Hydrocortisone IV:
− Adults: 2 mg/kg
− Children: 4-8 mg/kg stat, then 2 mg/kg
− Can be given up to qid prn.
> Change to oral medication as soon as possible.
ο If available give oxygen for severe exacerbation.
ο Consider aminophylline:
> Adults: 1 vial 250 mg slowly IV or PO in ½ glass of water
every 8 hours (as effective as IV medication)
> Avoid in children, esp. < 2 years (danger of convulsions)
unless in hospital under supervision.
> Avoid if patient is already taking aminophylline on a daily
basis.
> Treat underlying bacterial superinfection.
62
Monitor patient closely (symptoms and peak flow if possible).
ο Titrate medication to response of patient.
ο Ideal response: peak flow ≥ 80% of predicted or personal best
(response lasting > 3 hours)
Refer to hospital:
ο No longer-lasting response to bronchodilator
ο No improvement after oral glucosteroid treatment within 2-6 hours
ο Patients with suspected hypoventilation, exhaustion, distress or
peak flow 30-50% of predicted or personal best
Review treatment and give action plan to patient.
Refer to asthma clinic as soon as possible for further assessment; if
not possible arrange close follow-up in routine clinic.
4.5.2. Chronic obstructive pulmonary disease (COPD)
•
•
•
•
Often under-recognized and under-diagnosed
One of the leading causes of death worldwide
Risk factors: tobacco smoke, occupational dusts and chemicals (intense or
prolonged exposure), air pollution e.g. from biomass fuel used for cooking
and heating in poorly ventilated dwellings (especially women affected)
Chronic progressive, mostly irreversible disease of bronchi and terminal
alveoli
✎
Chronic cough
Chronic sputum production
Dyspnoea on exertion, getting progressively worse
Tachypnoea, wheeze
With progession of disease: signs of left and right ventricular failure
(with ankle oedema, increase of jugular pressure), respiratory failure
Diagnosis:
Spirometry (decrease in FEV1 and FEV1 /FVC)
Problem in our projects: only peak flow measurement possible at
present (COPD: poor diurnal variability)
63
Treatment:
Intermittent or worsening symptoms:
ο Salbutamol metered dose inhaler (MDI): 1-2 puffs as required or
(if problems with compliance or inhaler technique):
ο Salbutamol PO: adults: 2-4 mg prn up to qid
Persistent symptoms:
ο Salbutamol tablets PO: adults: 2-4 mg tid-qid
ο Long acting ß-agonists not available in our projects (too expensive)
Ongoing symptoms: add:
ο Aminophylline: adults 100-200 mg tid (10 mg/kg/day)
Repeated exacerbations: try (under supervision of an asthma clinic):
ο Beclomethasone metered dose inhaler (MDI): adults: 200 mcg bid
ο Trial period for 3 months – if no improvement or poor inhaler
technique: stop.
Acute exacerbation:
ο Prednisolone 30-40 mg PO for 7-10 days, then stop; long term
treatment with oral steroids not recommended (no benefit, too
many side effects).
Treat underlying infection with antibiotics e.g. amoxillicin 500 mg tid
for 7 days.
Refer to hospital if severe exacerbation.
Counsel smokers about necessity to stop smoking.
•
•
64
Staff should give demonstrations and – if available illustrated –
instructions to every patient with asthma or COPD attending the asthma
clinic.
Doctor should check inhaler technique of every patient treated with an
inhaler before continuing the prescription. Refer patients with poor inhaler
technique to asthma clinic as soon as possible or stop inhaler and give
oral medication (easier to take and therefore more effective than an
inhaler not used appropriately).
4.6. Tuberculosis
•
•
•
•
•
Typical disease of poverty with malnutrition, poor housing conditions,
overcrowding
About 95% occur in developing countries together with other diseases e.g.
HIV, diabetes mellitus.
Prevalence: pulmonary tuberculosis: 85%, extrapulmonary tuberculosis:
15%
Problem: infected people with open tuberculosis (usually adults) are a
source of infection for their family and friends (10-14 people per year).
Often problems with diagnosis if cough is present anyway e.g. due to
environmental pollution in Kolkata
Causative agent:
Mycobacterium tuberculosis
Transmission:
Bacilli spread in droplets of sputum
Transported via bloodstream or lymphatics to different organs in the
body
4.6.1. Pulmonary tuberculosis
•
Most common form of tuberculosis
Cough (> 2 weeks, productive)
Sputum; haemoptysis less common
Chest pain
Low grade fever, night sweats
Loss of weight
Dyspnoea
✎ Diagnosis:
Investigations should be done in every patient with a history of cough
longer than 2 weeks.
65
Direct smear microscopy for acid fast bacilli (AFB, Ziehl-Neelson
staining; in children > 10 years and adults):
1. First spot specimen when patient presents for the first time.
2. Early morning specimen (give specimen container to the patient
for a specimen next morning: all sputum collected in the first 2
hours)
3. Second spot specimen when the patient returns with the early
morning specimen
Chest x-ray (with strong suggestion of tuberculosis, even in sputumnegative patients):
ο Enlarged hilar lymph glands
ο Upper zone: patchy shadows with or without: cavitation,
calcification, diffuse small nodular opacities
ο Complications: pleural effusion (90% of pleural effusions are
caused by pulmonary Tb), pneumothorax etc.
Pneumonia
Bronchial asthma/COPD
Whooping cough (pertussis)
Lung cancer
4.6.2. Extrapulmonary tuberculosis
•
•
Common in people with low resistance e.g. due to AIDS, malnutrition,
other concomitant diseases or alcohol abuse
Any organ of the body involved; mainly cervical lymph nodes, spine, other
bones and joints, abdomen, brain
Tuberculous lymphadenitis (70%):
Lymph nodes swollen, non-tender
Mainly cervical lymph nodes affected
Abscess formation possible, occasionally with sinus formation
Diagnostic procedure:
ο FNAC (fine-needle aspiration and cytology; Ziehl-Neelson staining) if no improvement after a 10 days’ trial of antibiotics (e.g.
amoxicillin)
66
Tuberculosis of the spine (Pott’s disease, caries spine; 20%):
Back pain
Collapse of vertebrae, leading to gibbus formation
Some patients: signs of spinal cord compression, paraplegia of affected limbs
Paravertebral, gluteal or inguinal abscesses (cold abscesses)
Osteomyelitis, chronic fistulas, non-healing wounds
✎
Diagnosis:
ο X-ray (in case of wound or abscess if no improvement after up to
4 weeks’ trial with antibiotics)
ο FNAC of abscess with Ziehl-Neelson staining
Tuberculosis of the joint (2%):
Mainly affecting knees or ankles
Effusion, fistula formation, joint destruction
Abdominal tuberculosis (2%):
Peritoneal tuberculosis: ascites without any sign of liver disease
Intestinal tuberculosis: chronic abdominal pain, partial bowel obstruction, occasionally acute abdomen
Tuberculous meningitis (2%):
Mainly in children
Progressive weakness, nausea, headache, vomiting
Low grade fever
Neck stiffness (developing slowly)
Somnolence, coma
With cerebral/intracranial tuberculosis: headaches, late onset epilepsy
Diagnosis:
ο CSF examination (lymphocytosis, elevated protein)
ο Cerebral tuberculosis: CT-scan
4.6.3. Tuberculosis in children
•
Children under 5 years of age: greater risk than adults of developing tuberculosis after an infection
67
•
Often associated with malnutrition, HIV, history of measles and whooping
cough, poor nutritional status or smear-positive contact with pulmonary
tuberculosis among family or friends
✎
68
Often non-specific symptoms
Suggestive of tuberculosis:
ο Cough longer than 2 weeks not responding to 10 days’ course of
antibiotics (e.g. amoxicillin or cotrimoxazole)
ο Continuous or recurrent fever of unknown origin
ο Failure to thrive, loss of weight or failure to gain weight
ο Enlarged non-tender lymph nodes > 1 cm in neck, axilla or groins
of unknown origin persisting longer than 4 weeks
ο Gibbus of spine with or without paraplegia
Diagnosis:
Difficult to diagnose as younger children are not able to produce
sputum
In children > 10 years: direct smear microscopy for acid fast bacilli
(AFB, Ziehl-Neelson staining) x 3
In younger children: chest x-ray (?persistent area of consolidation,
miliary pattern of infiltrates, effusion)
Mantoux test with PPD (purified protein derivate):
ο Read after 72 hours.
ο < 5 mm: negative
ο 5-10 mm: in children < 5 years: result may be due to earlier BCG
immunization, therefore unreliable
ο > 10 mm: positive
ο Indicated only for small children who are not able to produce
sputum
ο Often negative in patients with low resistance (AIDS, measles,
malnutrition etc.)
ο Reading should be done by the same person to get reliable
results.
Treatment:
Problem:
ο Lack of patient compliance as symptoms improve or because of
side effects treatment is often stopped leading to the development
of resistant strains.
ο More successful: DOTS (directly observed therapy short-course)
where the course runs over 6 months and the drug intake is controlled by trained staff
2 phases for new patient:
ο Intensive phase: isoniazid/rifampicin/pyrazinamide/ethambutol or
streptomycin for 2-3 months
ο Continuation phase: isoniazid/rifampicin for 4-6 months (2-3 times/
week)
Refer to the local tuberculosis program, but remember: ill-functioning
programs are worse than no programs at all because of selection of
resistant bacteria and longer infective phases (more than 2 years) with
risk of infecting close contacts.
Pregnancy:
ο Avoid streptomycin.
st
ο Avoid rifampicin during the 1 trimester, but continue with regimen
if already started.
ο No problem with INH, pyrazinamide and ethambutol
Important: contact tracing (esp. for children < 5 years of age) and
treatment of infected people
☂
Prevention:
BCG immunization after birth
Information regarding cleanliness, hygiene, nutrition
4.6.4. Tuberculosis and AIDS
The incidence of tuberculosis is increasing with the incidence of HIV
infection.
In Africa: one third of AIDS patients are infected with tuberculosis and
40% of patients with tuberculosis are HIV-positive.
Tuberculosis during the early stage of HIV:
ο Usual clinical manifestations
69
ο
ο
ο
ο
PPD/Mantoux test positive
Chest x-ray: upper lobes affected, cavities
Rarely adenopathy
Extrapulmonary Tb in 10-15%
Tuberculosis during the late stage of HIV:
ο PPD/Mantoux test negative
ο Chest x-ray: atypical, lesions in the lower and middle lobe, no
cavities
ο Adenopathy common
ο Extrapulmonary Tb in more than 50%
Duration of treatment: 9 months (instead of 6 months)
BCG immunization: contraindicated in patients with full picture of HIV
infection (controversial guidelines regarding asymptomatic HIVpositive patients)
•
•
•
•
•
•
70
All patients with cough lasting longer than 2 weeks must have their
sputum checked for acid-fast bacilli.
Patients with extrapulmonary tuberculosis must be investigated for
pulmonary tuberculosis (sputum AFB).
Fine-needle aspiration should be done on all swollen lymph nodes not
responding to a 10 days’ course of antibiotics.
Always think of tuberculosis of spine or bones in patients with chronic
effusion of joints, fistula formation or progressive destruction of a single
large joint.
Think of abdominal tuberculosis in patients with ascites of unknown origin.
Treatment for tuberculosis should only be started and supervised by
trained staff according to a National Tuberculosis Program.
Gastrointestinal Problems
5. GASTROINTESTINAL PROBLEMS
5.1. Gastritis
Causative agents:
Bacterial (Helicobacter pylori, 80-90%)
Non-steroidal antiinflammatory drugs (NSAIDs, 7-15%)
Autoimmune (Vit. B12 deficiency, 3-6%)
Epigastric pain, nausea, vomiting
Complications:
ο Bleeding (history of haematemesis or melaena; tachycardia, hypotension)
ο Perforation (severe pain, guarding)
In developing countries: mainly intestinal parasites (giardia lamblia,
helminths)
Think of hunger pains!
Also: reflux oesophagitis, pancreatitis, disease of liver, gallbladder or
large bowel, myocardial infarction (posterior wall)
Note:
In our projects diagnostic procedures e.g. endoscopy are only indicated in
rare cases; treatment should therefore be given when diagnosis is
suspected.
Treatment:
Advice to avoid carbonated drinks, hot spicy food, alcohol, cigarettes,
acetylsalicylic acid, NSAIDs
Antacids:
ο Magnesium trisilicate qid prn (1-2 hours after meals and 1 hour
before going to bed)
71
ο
Side effects: reduced absorption of other drugs; risk of accumulation with renal impairment
H2 blocker:
ο Ranitidine: adults: 150 mg bid or 300 mg nocte
Helicobacter pylori:
•
Important cause of gastric or duodenal ulcer
•
Problems in developing countries:
Few data exist about eradication and relapse rate.
Diagnostic methods e.g. endoscopic biopsies for histology, serology
or breath tests are not available in our setting.
Substitution of clarithromycin is difficult, substitution of proton pump
inhibitor with H2 blockers poorly investigated.
Risk of drug resistance due to inadequate treatment
Poor compliance with multiple drug regimens (adverse effects occur in
up to 80%)
Note:
In our projects eradication of Helicobacter pylori can only be considered in
indigent patients with a diagnosis of bleeding ulcer or perforation, with
recurrent gastric or duodenal ulcer if an operation can be avoided.
Treatment:
French triple therapy (for 7 days):
ο Amoxicillin 1 g bid plus
ο Clarithromycin 500 mg bid plus
ο Omeprazole 20 mg bid
Second choice: Italian triple therapy (for 7 days):
ο Metronidazole 400 mg bid plus
ο Clarithromycin 250 mg bid plus
ο Omeprazole 20 mg bid
This treatment should be restricted to patients with severe illness because of
costly medication and risk of poor compliance.
72
5.2. Hepatitis
5.2.1. Hepatitis A
•
•
•
Common in developing countries due to poor housing and living
conditions, lack of proper disposal of rubbish and poor standards of
sanitation and hygiene
Transmission: faecal-oral route
Mainly children affected, asymptomatic in 50-90%; adults: fulminant forms
possible
5.2.2. Hepatitis B
•
•
•
•
•
•
•
Transmission: parenteral route (blood and blood products, IV-drugs), sexual
intercourse (65%), mother-to-child transmission
Worldwide: prevalence 6%
HbsAg prevalence: Philippines, Kenya: 5-10%; India, Bangladesh, South
America: 1-5%
In 5-10%: chronic infection
Self-limiting in 90% of adult patients (children: less than 10%); chronic
hepatitis in 5%
Main cause for development of hepatocellular carcinoma worldwide
WHO: Hepatitis B vaccination recommended as part of the ”Expanded
Program on Immunization”
5.2.3. Hepatitis C
•
•
•
•
Transmission: parenteral route (e.g. shared needles in drug users,
multiple use of needles for medical purposes), rarely with sexual intercourse
Worldwide: 3% prevalence
Mainly asymptomatic forms
Chronic hepatitis in 50% of patients (20% of patients: cirrhosis of the liver
with 1% developing liver cell carcinoma)
73
5.2.4. Hepatitis D
•
•
Transmission: parenteral route with blood and blood products, sexual
intercourse
Only in patients with hepatitis B or as superinfection in chronic HbsAg
carriers
5.2.5. Hepatitis E
•
•
Transmission: faecal-oral route, possible: zoonotic spread (virus found in
cows, pigs, goat and other animals)
Severe illness in pregnant women: mortality: 20% when infection occurs in
the third trimester
Common aspects:
Common: asymptomatic form or mild jaundice
Symptomatic:
ο Weakness, fever
ο Nausea, upper abdominal pain, jaundice
ο Dark urine, clay coloured stools
ο Severe forms with liver failure possible with hepatitis A, B or
hepatitis E
✎
Important because of therapeutic consequences
Malaria
Gallstones, cholangitis, blocked bile ducts
schistosomiasis
due
to
ascaris,
Diagnosis:
Not indicated as there are no therapeutic consequences (interferon or
ribaverin too expensive in our setting)
Treatment:
Bed rest
Supportive treatment e.g. hydration, nutritious diet
Antipyretics and analgesics are contraindicated in the acute phase
due to risk of side effects.
74
☂
Prevention:
Every pregnant mother should be tested for HbsAg, either by us or at
the official antenatal check up so that babies can be immunized
straight after birth when possible.
Good hygiene (sanitary conditions, safe disposal of faeces)
Once – only use of sterile needles
Avoidance of application of IV- or IM-medication where oral medicine
is effective
5.3. Diarrhoea
•
Each year there are 2.5 million deaths from diarrhoea.
Treat early – delay is dangerous.
•
•
•
Definition of diarrhoea: 3 or more watery stools/day
This definition is not useful in children: better ask mother for change of
bowel habits (e.g. watery stool, 3 times/day instead of 3 times/week);
breast-fed children tend to have loose motions anyway.
Persistent diarrhoea: duration longer than 14 days
Questions to ask:
Fever present?
Blood in stool?
Duration of symptoms?
Any other symptoms (e.g. vomiting, cough, ear ache, convulsions)?
Preexisting illness (measles recently)?
Concurrent medication? Immunizations?
Fluid intake sufficient?
Malnutrition? (children: Road to Health Chart or MUAC)
Signs and symptoms of dehydration?
ο ?Child restless, lethargic or unconscious
ο Skin turgor (?dry)
ο Nutritional status (?malnutrition)
Check temperature.
75
Diarrhoea with fever and blood:
• Shigellosis
• Campylobacter enterocolitis
• Salmonella enterocolitis
• E. coli haemorrhagic colitis (EHEC)
Diarrhoea with fever, without blood:
• Salmonella enteritis
• Campylobacter enteritis
• Malaria
• E. coli enteritis (EPEC)
• Typhoid fever
• Extraintestinal causes, esp. in children
Diarrhoea without fever, with blood:
• Amoebic dysentery
• Schistosomiasis
• Trichuris (severe infection)
Diarrhoea without fever, without blood:
• Viral infections e.g. rotavirus in children
• Food poisoning e.g. by Staphylococcus
perfringens
• Traveller’s diarrhoea (E. coli - ETEC)
• Giardiasis (persistent diarrhoea)
• Cholera
5.3.1. Diarrhoea with fever and blood
5.3.1.1. Shigellosis
•
•
76
Endemic in most developing countries
Most common cause of bloody diarrhoea worldwide
aureus,
Clostridium
Causative agents:
Mainly shigella dysenteriae, shigella flexneri
Transmission:
Person-to-person
Infection acquired by ingestion of contaminated water or food
✎
Most common in children under 5 years of age
Acute onset: fever (common), malaise
Abdominal cramps
Bloody mucoid diarrhoea, anorexia
Complications:
ο Dehydration
ο Convulsions
ο Perforation of bowel
ο Haemolytic uraemic syndrome
Diagnosis:
Faecal or rectal swabs
Laboratory findings:
Low sodium
Low blood glucose
Treatment:
Rehydration (see chapter Dehydration, p.89)
World-wide resistance to antibiotics, therefore use only in severe
cases.
Treatment should ideally be based on susceptibility data from shigella
strains isolated in the area.
Older antibiotics often won’t work, therefore use 5-fluoroquinolones
e.g. ciprofloxacin:
ο Adults: 500 mg bid
ο Children: 30-40 mg/kg in 2 divided doses; not officially recommended as yet (risk of cartilage damage) but use if benefit outweighs
risk.
77
Supportive (for pain, fever):
ο Hyoscine butylbromide:
> Children 6-12 years: 10 mg tid prn
> Children > 12 years, adults: 10-20 mg tid prn
ο Paracetamol:
> Children: 30 mg/kg in 3-4 divided doses prn
> Adults: 500 mg qid prn
5.3.1.2. Campylobacter enterocolitis
Causative agent:
Campylobacter jejuni
Transmission:
Faecal-oral, human-to-human, animal-to-human (e.g. from infected
poultry)
Infection also acquired by ingestion of contaminated food, water
Most common under the age of 1 year
Often watery diarrhoea, abdominal pain, vomiting
Also (in immuno-compromised patients): severe bloody diarrhoea with
fever
May be followed by reactive arthritis.
Predisposing factor for development of Guillain-Barré syndrome
Usually self-limiting (2-7 days)
Treatment:
Rehydration
Antibiotic treatment: give only in severe cases; problem: worldwide
resistance emerging due to use of macrolides and especially
quinolones in the poultry industry.
ο Erythromycin:
ο Ciprofloxacin:
> Adults: 500 mg bid
78
>
ο
Children: 30-40 mg/kg in 2 divided doses; not officially
recommended as yet (risk of cartilage damage) but use as
second line agent if benefit outweighs the risk.
Duration of treatment: 5 days
5.3.2. Diarrhoea with fever, without blood
5.3.2.1. Salmonella enteritis
Causative agent:
Salmonella species
Transmission:
Faecal-oral
Infection acquired by eating contaminated food
✎
Incubation period 12-48 hours
Fever, headache, vomiting
Diarrhoea first watery, later with blood and mucus (salmonella enterocolitis)
Abdominal cramps
Complications:
ο Generalized bacteraemia with typhoid-like symptoms
ο Reactive arthropathy
ο Iridocyclitis
Diagnosis:
Isolation of bacteria from stool
Treatment:
Usually self-limiting
Rehydration
Antibiotic therapy: problematic due to resistant organisms and risk of
prolonging the intestinal carriage of salmonella, therefore use only in
severe cases:
ο Amoxicillin:
79
ο
ο
ο
> Adults: 500-1000 mg tid
Cotrimoxazole:
> Children: 8 mg/kg TMP + 40 mg SMZ in 2 divided doses
> Adults: 960 mg (160 mg TMP + 800 mg SMZ) bid
Older antibiotics often won’t work, therefore use 5-fluoroquinolones e.g. ciprofloxacin according to local information:
> Children: 30-40 mg/kg in 2 divided doses; not officially
recommended as yet (risk of cartilage damage), but use if
benefit outweighs the risk.
5.3.2.2. Typhoid fever
•
Illness can be endemic worldwide
Causative agent:
Salmonella typhi
Transmission:
Human-to-human (asymptomatic carriers)
Infection by ingestion of contaminated water or food
80
Incubation period 10-20 days
Duration of untreated illness: about 4 weeks
st
1 week:
ο Non-specific symptoms:
> Headache
> Constipation, diarrhoea
> Cough
> Remittent fever (increasing day by day, temperature spike in
the evening)
> Relative bradycardia
Later:
ο Very unwell:
> Abdominal pain, diarrhoea (like ”pea-soup”)
> Hepatosplenomegaly
>
>
>
Altered mental state, meningitis, deafness
Rose spots (fade on pressure; difficult to distinguish in dark
skin)
Complications:
− Perforation or haemorrhage of the bowel
− Myocarditis, pneumonia,
− Haemolytic uraemic syndrome
− Disseminated intravascular coagulation
✎
Malaria
Dengue fever
Diagnosis:
Consider endemic areas.
Clinical manifestations – as there is no reliable test for typhoid fever
treat if disease is suspected.
FBC (leukopenia, leucocytosis)
Blood culture, stool sample
Widal test (test for antibodies; not available in every project):
ο Always check for fourfold increase in antibody titres and consider
the clinical manifestations!
ο Problems: antibody titres can be high after infections with other
salmonellae or after immunization; some patients show no
antibodies or no rise in antibody titres.
Treatment:
Rehydration
Antibiotics:
ο Treat according to known susceptibility of bacteria in the area.
ο Chloramphenicol:
> Problem: drug resistance, high relapse rate, risk of carrier
status
> Adults: 1000 mg tid
> Duration of treatment: 14 days
ο Amoxicillin:
81
ο Cotrimoxazole:
> Children: 8 mg/kg TMP + 40 mg SMZ in 2 divided doses
ο 5-fluoroquinolones e.g. ciprofloxacin:
recommended as yet (risk of cartilage damage) but use as
second line agent if benefit outweighs the risk.
> Duration of treatment: 5-7 days
> In areas with possible bacterial resistance give for 14 days.
Corticosteroids:
ο For patients with severe illness or confusion
ο Dexamethasone IV: 3 mg/kg over 30 minutes, then 1 mg/kg over
6 hours
Refer to hospital if illness is severe.
Chronic carriers (1-3%) should be treated if they are at risk of
spreading the disease (e.g. food handlers).
5.3.2.3. Extraintestinal infections in children
•
•
•
•
Always examine children with fever and diarrhoea thoroughly.
Check for tonsillitis, otitis media, pneumonia, urinary tract infection,
measles, especially if persistent diarrhoea (lasting longer than 14 days).
Always think of malaria!
Treatment according to diagnosis and degree of dehydration (see
Treatment plans A, B, C, p.90, 91, 92)
5.3.3. Diarrhoea without fever, with blood
5.3.3.1. Amoebiasis
Causative agent:
Entamoeba histolytica
82
Transmission:
Faecal-oral
Infection acquired by swallowing cysts in contaminated water.
Worldwide distribution; mainly in countries with poor sanitation when
human faeces are used as fertilizers
✎
Mainly asymptomatic carriers of cysts (90%)
Amoebic dysentery:
ο Slow onset; diarrhoea with blood and mucus; abdominal cramps;
lasting for several weeks
ο Abdominal tenderness
ο Occasionally fever
ο Attacks can recur for years.
Amoebic liver abscess:
ο Most common form of extraintestinal manifestation
ο Pain and tenderness over the liver
ο Hepatomegaly
ο Intermittent fever with rigors and sweating
ο Cough with lung involvement
ο Dyspnoea with anaemia
Diagnosis:
Amoebic dysentery: microscopic examination of stool smear (freshly
passed specimen) for trophozoites
Amoebic liver abscess: ultrasound scan, FBC (leucocytosis, anaemia)
Treatment:
Amoebic dysentery:
ο Rehydration
ο Treatment only after ineffective treatment for shigellosis
ο If amoebiasis is suspected give antibiotics straight away (do not
wait for faecal analysis).
ο Metronidazole:
> Children < 12 years: 30 mg/kg PO in 3 divided doses (severe
cases: 50 mg/kg)
> Adults: 500 mg PO tid
83
> IV: same dosage
> Inform patient to avoid alcohol.
ο No treatment necessary for asymptomatic patients with cysts on
faecal analysis
ο Tinidazol (infection with resistant amoebae):
> Advantage: longer half-life, shorter duration of treatment
> Children > 6 years: 50-60 mg/kg od
> Adults: 2 g od
Amoebic liver abscess:
ο Treatment for 10 days sufficient
ο During treatment: abscess may first increase in size
ο Even with correct treatment: abscess can take up to 6 months to
disappear.
ο Treatment with diloxanide: not an option for our projects because
of high percentage of asymptomatic carriers and high re-infection
rate
5.3.4. Diarrhoea without fever, without blood
5.3.4.1. Traveller’s diarrhoea
Causative agent:
Enterotoxicogenic E. coli (ETEC)
Transmission:
Faecal-oral
Infection acquired by ingestion of contaminated food or water
Self limiting; conferring longer lasting immunity (therefore visitors are
more susceptible than residents)
Watery diarrhoea, vomiting, anorexia
Dehydration in malnourished children
Treatment:
Fluid replacement
84
Antibiotics:
ο Resistance widespread
ο For severe illness: ciprofloxacin 500 mg bid for 1-5 days
5.3.4.2. Cholera
Causative agent:
Vibrio cholerae
Transmission:
Faecal-oral
Infection acquired by ingestion of contaminated water or food
Usually panepidemic; in areas with poor sanitation and hygiene
Incubation period 2 hours to 5 days
Profuse watery stools with mucus (rice water stools) leading to severe
dehydration
Vomiting
Death due to hypovolaemic shock and renal failure
Treatment:
Treat if diagnosis is suspected.
Rehydration as quickly as possible e.g. with Ringer’s Lactate solution
(see Dehydration, p.89)
Antibiotics:
ο Doxycycline:
> Adults only: 300 mg single dose
ο Cotrimoxazole:
> Children 8 mg/kg TMP + 40 mg SMZ in 2 divided doses
5.3.4.3. Giardiasis
Causative agent:
Giardia intestinalis (Giardia lamblia)
85
Transmission:
Faecal-oral: infection acquired by swallowing cysts in contaminated
water or food
Human-to-human
✎
Often: asymptomatic carrier state
Diarrhoea, often for weeks, frothy, pale, offensive; with flatus
Nausea, abdominal cramps
Weight loss, often with malabsorption
Failure to thrive in young children
Secondary lactase deficiency
Diagnosis:
Cysts in stool smear
Trophozoites in freshly passed specimen
Treatment:
Rehydration
Metronidazole:
ο Children < 12 years: 30 mg/kg in 3 divided doses over 3 days (short
course) or 15 mg/kg in 3 divided doses for 7 days
ο Adults: 800 mg bid for 3 days (short course) or 200 mg tid for 7
days
ο Inform patients to avoid alcohol.
Albendazole:
ο Adults: 400 mg od for 5 days
Tinidazole (infection with resistant parasites):
ο Advantage: longer half-life, short duration of treatment
ο Children ≥ 6 years: 50-60 mg/kg od
ο Adults: 2 g od
86
•
Even if the causative agent is not known (no stool culture
available) it is important to have some idea what you are treating!
•
When treating diarrhoea always think of rehydration first (see chapter
Dehydration, p.89).
Do not use antibiotics routinely! They are often not necessary in the
treatment of diarrhoea, have the risk of adverse reactions and
development of resistant bacteria.
There is wide-spread resistance to amoxicillin and co-trimoxazole,
therefore use ciprofloxacin if appropriate in severe diarrhoea. Always
check with the project information.
Do not forget to treat underlying diseases.
•
•
•
•
Bloody diarrhoea in children: with fever think of shigellosis first,
without fever: think of amoebiasis first; then consider other causes.
If amoebiasis is suspected use metronidazole.
•
With severe diarrhoea always give zinc 20 mg/day for 14 days to
children > 6 months (10 mg/day for infants < 6 months) as it has been
shown to reduce the severity and duration of diarrhoea.
•
Avoid antimotility drugs like loperamide (Imodium ), antisecretory
drugs like kaolin or charcoal and antiemetics: rehydration is far more
important and they are contraindicated for children under 5 years of
age anyway.
•
•
Give advice regarding feeding to correct or prevent malnutrition.
Give advice regarding prevention of diarrhoea: breastfeeding, good
personal hygiene (e.g. washing hands with soap before eating),
sanitation (e.g. safe disposal of faeces), safe drinking water, safe
handling of food.
Advice to prevent traveller’s diarrhoea: cook it, boil it, peel it or leave
it.
•
•
®
Do not forget to encourage immunizations e.g. against measles.
87
Treatment suggestions:
Diarrhoea with fever and blood:
First think of shigellosis; treatment: ciprofloxacin + ORS.
Diarrhoea with fever, without blood:
Very important: differential diagnosis and treat accordingly (including
ORS).
Diarrhoea with blood, without fever:
First think of amoebiasis; treatment: metronidazole + ORS.
Diarrhoea without fever, without blood:
First think viral infection or uncomplicated E. coli-infections: treat with
ORS.
88
5.4. Dehydration
Delay is dangerous!
•
•
•
•
Mainly caused by diarrhoea and/ or vomiting
Main problem in children < 5 years as there is relatively greater fluid loss
through the skin
Treatment with oral rehydration solution: sugar increases the absorption of
water; therefore it is important to add sugar to electrolyte solution.
Zinc, an important micronutrient for a child’s health, is lost during
diarrhoea. Studies have shown that treatment with zinc shortens the
severity and duration of diarrhoea. It is therefore important to give zinc to
all children with severe diarrhoea.
Clinical manifestations (assessment of dehydration; WHO):
Degree of
dehydration
Loss of
body
weight
Condition
Eyes
Thirst
Skin pinch
None or
minimal
< 5%
Alert
Normal
None
Goes back
immediately
Sunken
Drinks
eagerly,
very
thirsty
Goes back
slowly
Sunken
fontanelle,
tachypnea,
tachycardia,
decreased
urine output
Sunken
Unable to
drink or
drinks
poorly
Goes back
very slowly
(≥ 2
seconds)
Hypotension,
very dry
mouth,
anuria,
circulatory
failure
Moderate
(some)
Severe
5-10%
> 10%
Restless,
irritable
Lethargic,
unconscious
Other signs
89
Treatment (according to WHO):
None or minimal dehydration (< 5%):
Outpatient treatment (Treatment plan A):
Give as much fluid as the patient will take.
ο Breastfed children: continue breast feeding; feed frequently and
for longer periods; add ORS or plain water.
ο Non-exclusively breastfed children: give ORS, clean water or
food-based fluids (e.g. soup, rice water, yoghurt drinks, juice of
young coconut).
Rehydration:
ο Oral rehydration solution (ORS): for children up to 2 years:
50-100 mL after each loose stool; for children 2-10 years:
100-200 mL after each loose stool, children > 10 years: as much
as tolerated
ο ORS to be given at home: children up to 2 years: 500 mL/day,
children 2-10 years: 1 litre/day, children > 10 years: 2 litres/day
ο If child vomits, wait for 10 minutes then give ORS more slowly e.g.
1 spoonful every 2-3 minutes.
ο Always explain the mother how to prepare and use ORS.
ο Continue treatment until diarrhoea stops.
Zinc supplement: infants below 6 months: 10 mg/day, children
6 months to 5 years: 20 mg/day; give for 10 to 14 days.
Nutrition: for older children or adults carry on with food (nutritious,
easily digestible e.g. cereal, meat, fish, fresh fruit juice, mashed
banana); small amounts in frequent intervals; after illness: one
additional meal daily for 2 weeks
Explain to mother to come back or go to hospital if there is no
improvement within three days or deterioration at any time, fever or
blood in the stools.
If ORS is not available teach the mother how to prepare a rehydration
drink: 1 litre of boiled water, 1 level teaspoon of salt, 8 level teaspoons of
sugar.
90
Moderate (some) dehydration (5-10%):
Oral rehydration (Treatment plan B):
ο
Within the first 4 hours of treatment give ORS according to
weight or age:
ο
Age:
> < 4 months
> 4-11 months
> 12-23 months
> 2-4 years
> 5-14 years
> > 14 years
weight (kg):
<5
5-8
8-11
11-16
16-30
> 30
ORS (mL)
200-400
400-600
600-800
800-1200
1200-2200
2200-4000
ο
Initially (when dehydrated) adults can take up to 750 mL of
ORS/hour, children up to 20 mL/kg/hour.
ο Encourage the mother to continue breastfeeding; for nonbreastfed infants < 6 months give an additional 100-200 mL of
clean water during the first 4 hours.
ο Give ORS in small amounts (use teaspoon for smaller children,
cup for bigger children); if vomiting wait for 10 minutes then
continue more slowly.
ο If patient wants more water than recommended above give more.
ο If the child’s eyelids become oedematous stop ORS, give plain
water or breast milk and treat as plan A (no dehydration) after
oedema has stopped.
ο Check regularly to see if there are any problems.
Reassess after 4 hours checking for signs of dehydration and treat
accordingly (plan A, B or C):
ο If there is no dehydration (child less irritable, passing urine) start
plan A.
ο If there are signs of some dehydration repeat plan B and start to
offer food, milk or juice according to plan A.
ο If there are signs of severe dehydration start IVI and treat for plan
C.
Maintenance therapy (in addition to rehydration therapy):
ο Breastfed infants: mothers should continue breastfeeding as much
and as long as the child wants.
91
ο
Non-breastfed infants: give additional 100-200 mL of plain water
during the rehydration period, afterwards give fluids normally
taken by the child (e.g. formula feeds, water etc.).
ο Older children, adults: give as much fluids, e.g. water, juice, milk
etc. as wanted and tolerated.
Feeding:
ο During first 4 hours of rehydration do not give any food except
breast milk.
ο After 4 hours if the child has still some dehydration and ORS is
being given start food and give every 3-4 hours.
If the mother leaves the clinic before the end of the rehydration period:
ο Explain to mother about the treatment and how to much ORS to
give to finish initial 4-hour treatment period.
ο Give enough ORS for the completion of rehydration and 3 more
days according to treatment plan A.
ο Explain to give ORS until diarrhoea stops, to give more food to
prevent malnutrition and to bring the patient to hospital or clinic
straight away if there is no improvement or deterioration.
ο All children older than 4-6 months should be given some food
before being sent home.
Give zinc supplements: infants < 6 months: 10 mg/day, children from
6 months to 5 years: 20 mg/day for 10 to 14 days.
Severe dehydration (> 10%):
92
IV rehydration (Treatment plan C):
Admit to hospital for IV rehydration (e.g. with Ringer’s Lactate solution).
ο Start IVI immediately:
> Infants (< 12 months): 30 mL/kg in 1 hour (can be repeated
once if radial pulse is still very weak or not detectable), then
70 mL/kg in 5 hours
> Children ≥ 12 months, adults: 30 mL/kg in 30 min (can be
repeated once if radial pulse is still very weak or not
detectable), then 70 mL/kg in 2 ½ hours
ο Reassess every 15-30 minutes until strong radial pulse is present,
then every 1-2 hours; if no improvement give fluids more rapidly.
ο Give ORS (5 mL/kg/hour) as soon as the child will take fluids.
ο
If the parents refuse to take the child to hospital or transport is not
readily available: evaluate patient after 3 hours (older child, adult) or
6 hours (infant < 6 months) using assessment chart (see above) and
treat accordingly (treatment plan A, B or C).
93
Malnutrition and Micronutrient Deficiencies
6. MALNUTRITION AND MICRONUTRIENT DEFICIENCIES
6.1. Malnutrition
•
•
•
•
94
In developing countries the most common nutritional problems are caused
by lack of protein and energy, fats, vitamins, minerals, iron and iodine (due
to lack of food, problems with absorption and metabolization).
Underlying causes: poverty, inappropriate food, poor weaning practice; also
infections such as diarrhoea, pulmonary tuberculosis, measles, malaria,
worms, or diseases like tuberculosis or HIV
Differential diagnosis: failure to thrive (think of underlying diseases e.g.
heart failure or other chronic illnesses)
Often the second youngest child affected: after being weaned there is not
enough food rich in protein or the baby is reared on diluted contaminated
milk (due to poverty of the parents not enough formula milk available, lack
of cleanliness).
Marasmus
Kwashiorkor
Cause
Diet low in proteins and
calories
Diet low in proteins but
containing carbohydrates
Clinical
manifestations
Growth retardation < 60%
of normal
Growth failure
Loss of subcutaneous fat,
loss of muscles, severe
wasting
Muscle wasting
Old man’s face
Moon face
No oedema
Pitting oedema of dependent
areas, esp. lower legs, feet,
ankles
No mental signs
Psychomotor changes, e.g.
apathy
No hair changes
Hair changes e.g. sparse hair,
dyspigmentation
Hepatomegaly
Laboratory findings
Serum albumin normal
Serum albumin low
Age peak
< 18 months
18-36 months
Note:
•
•
•
Oedema can conceal the fact that the child is undernourished and vitally
threatened. There is a risk of overlooking malnutrition if only the weight of
the child is measured.
A child with oedema of both feet is malnourished (regardless of weight)
until proven otherwise.
Oedema must be recorded in the Road to Health Chart!
95
Criteria for assessing the nutritional status:
Birth weight
Weight-for-age
Weight-for-height
Mid-Upper Arm Circumference (MUAC)
Road to Health Chart:
Standard for weight-over-age in percentiles:
ο Tool for monitoring growth development and for early detection of
children at risk of malnutrition and severe illness
ο Body weight related to that of children of same age
th
th
rd
ο 3 percentiles: 97 , 50 , 3 percentile
rd
ο Body weight in 3 percentile: 3% of children of the same age
weigh less, 97% weigh more
Important:
ο Assessment of child development through monitoring of weight
progression
Danger signs:
rd
ο Children below the 3 percentile
ο Declining weight curve
Mid-Upper Arm Circumference:
Correlating with weight of children below 5 years of age
Rapid assessment tool for screening
Checked on middle of hanging upper arm with tape measure
Danger signs:
ο MUAC 12.5-13.0 cm: must be monitored closely
ο MUAC 11.5-12.5 cm: moderately undernourished
ο MUAC below 11.5 cm: severely malnourished
96
•
•
•
•
At every consultation children under the age of 5 years must be weighed
and the results recorded in the Road to Health Chart.
rd
Any child with weight below the 3 percentile is probably underweight.
Declining weight curves are a sign that the child is at risk; weight falling
rd
below the 3 percentile is cause for alarm.
In undernourished patients the MUAC should be checked too: MUAC
below 11.5 cm indicates severe malnutrition.
Treatment:
Appropriate diet:
ο Food advice
ο Monitoring of weight-for-height in feeding centers, hospital or
during consultation hours
Admission of children with marasmus and kwashiorkor to hospital for
intensive therapy
ο Admission criteria:
> Weight-for-height < 70% of median
> Bilateral lower limb oedema
> MUAC < 11.5 cm
> Presence of infection, seriously ill child
ο Discharge criteria:
> Weight-for-height ≥ 85% of median
> Weight increase
> Improvement of overall condition
> Disappearance of lower limb oedema
Treatment of concomitant infections
Emotional support
☂
Prevention in developing countries (WHO):
Exclusive breastfeeding during the first 6 months of life
Slow introduction of solids in addition to breast milk after 6 months
Breastfeeding in addition to solids during the first 2 years of life
Own plate for each child, not sharing with siblings or mother
Support through health worker
97
6.2. Micronutrient Deficiencies
6.2.1. Vitamin D deficiency (rickets, osteomalacia)
•
•
•
Common in areas where children and women are not exposed to sufficient
sunlight for cultural and social reasons
Most common in infants (due to vitamin D deficiency of mother and low
amounts of vitamin D in breast milk) and young children
Can also be caused by renal failure, liver cirrhosis, and epilepsy treatment
(e.g. carbamazepine, phenytoin, phenobarbital).
6.2.1.1. Rickets
✎
Developing within the first 2 years of life
Often asymptomatic or nonspecific symptoms like tiredness and
aches
Pain in bones, mainly legs
Muscle weakness, tremor, unsteady gait
Swollen epiphysis at wrists, ankles and costochondral junction (rickety
rosary), flattened chest (pigeon chest), deformities of legs (bow legs),
softening of the skull (craniotabes)
If severe illness: hypocalcaemia leading to muscle spasm (cramps),
laryngeal stridor and seizures
Diagnosis:
History, clinical manifestations
Only in rare cases: further investigations necessary e.g.:
ο X-ray of wrist: line of osteochondral calcification of radius and ulna
broadened, surface cupped and frayed; for confirmation of
diagnosis
ο Fasting serum calcium may be low.
ο Serum phosphatase (low), alkaline phosphatase (raised)
Treatment:
Vitamin D + Calcium:
ο Vigantol® oil (Colcalciferol) PO:
> 1 mL = 30 drops containing 0.5 mg or 20.000 IU Vit. D3
> Give 7 drops (6000 IU) od PO
98
>
>
>
Plus calcium 1000 mg od PO
Duration of treatment: 6 weeks
Reversal of biochemical changes seen after 6 weeks; bones
take longer to adjust.
ο Arachitol® IM:
> 1 mL = 7.5 mg or 300 000 IU Vit. D3 in oily base
> Give 300 000 IU single dose IM; repeat dose of vitamin D3
300 000 IU IM after 3 months.
> Plus calcium 1000 mg od PO for 4 weeks
Education regarding exposure to sunlight and food rich in Vit. D e.g.
eggs
Check for underlying causes and treat accordingly.
6.2.1.2. Osteomalacia
Mainly in women
Symptoms often during late pregnancy or after delivery
Bone pain (ribs, legs), softened bones with risk of fractures
Unsteady gait
Hypocalcaemia leading to cramps
Anaemia
✎
Tuberculosis of spine
Diagnosis:
History (?young Muslim women, medication)
X-ray: uncalcified osteoid tissue at growing ends of bone, fractures
Serum phosphatase (low), alkaline phosphatase (raised)
Investigations according to possible underlying causes
Treatment:
Arachitol® IM:
ο Vit D3 300 000 IU Vit. D3 single dose IM, repeat dose after
3 months
Plus calcium: 1000 mg od PO for 4 weeks
If severely ill: refer to hospital
99
☂
Prevention:
Exposure to sunlight
Food rich in Vit. D e.g. eggs
6.2.2. Vitamin A deficiency
•
•
•
•
Mainly in children and pregnant women of rice-eating families in South
Asia, South-East Asia
Reduced incidence in coastal areas (consumption of red palm oil high in
carotenes)
Most common cause of blindness in childhood in endemic areas
Often manifestation of underlying deficiency with severe infections e.g.
measles
Xerophthalmia, including:
ο Night blindness (first evidence)
ο Conjunctival xerosis: conjunctiva dry, wrinkled; Bitot’s spots (usually
bilateral; looking like foam, can be wiped off)
ο Corneal xerosis: dry cornea, corneal ulcers
ο Keratomalacia: perforation of cornea, prolapse of iris, destruction
of the eye
Treatment:
Vitamin A:
ο Children 6 to 12 months: 100 000 units day 1, 2 and 8
ο Children > 1 year, adults (excluding women of childbearing age,
pregnant women): 200 000 units day 1, 2 and 8
With corneal involvement: chloramphenicol eye drops tid for 7-10 days
Refer to specialist (EENT) in case of keratitis.
Treat concomitant diseases.
Prophylaxis:
WHO recommendations for high-risk areas (insufficient intake of
vitamin A with food):
ο Children 6 to 12 months: 100 000 IU stat, then
ο Children > 1 year: 200 000 IU every 6 months
100
ο
ο
ο
rd
Pregnant women: 25 000 IU every week after 3 month of
pregnancy
Mothers: 200 000 IU within 1 month of delivery of a child
Infants < 6 months: 50 000 IU single dose if they are not breastfed
or if they are breastfed and the mother did not receive
supplemental vitamin A
•
•
☂
Do not give high dose vitamin A prophylaxis to women of child bearing age
(risk of malformations of fetus).
Give vitamin A to children with measles (see chapter Measles, p.128) to
reduce risk of blindness and mortality of the disease.
Prevention:
Education about diet rich in vitamin A such as yellow vegetables and
fruits such as carrots, pumpkin, mango, red palm nuts, yellow corn/
maize, sweet potatoes, also dark green leafy vegetables, dairy
products, fish liver oils, egg yolk
6.2.3. Iron deficiency
See chapter Anaemia, p.32
101
Parasitic Diseases
7. PARASITIC DISEASES
7.1. Helminthiasis
Most common helminths:
• Soil transmitted helminths (nematodes): enterobius vermicularis (pinworm,
threadworm), trichuris trichiura (whipworm), ascaris lumbricoides
(roundworm), ancylostoma duodenale (hookworm), strongyloides
stercoralis
• Trematodes: schistosoma japonicum, mansoni, haematobium
• Cestodes: taenia saginata, taenia solium
7.1.1. Enterobius vermicularis (pinworm, threadworm)
•
•
•
Common in children
Often the whole family affected and people living in crowded conditions
Size: 1 cm; colour: white
Transmission:
Direct from anal or perianal region to mouth (under fingernails) or by
soiled night clothes or bed linen
Retroinfection possible: eggs hatch on the anal mucosa, larvae
migrate up the bowel.
♻
Life cycle:
Eggs are ingested; worms invade the terminal ileum, caecum and
appendix.
Mature female deposits eggs near the anus.
102
Mainly perianal pruritus (nocturnal, when female migrates to anus)
Possible:
ο Right iliac fossa pain (DD: appendicitis)
ο Vulvitis (worm migrating up the vulva)
ο Non-specific symptoms like insomnia, loss of appetite, weight loss
Parasitic Diseases
✎
Diagnosis:
Clinical manifestations
Treatment:
Treat the whole family.
Mixed infections with other worms possible
Albendazole:
ο Children < 2 years: 200 mg single dose
ο Children > 2 years, adults: 400 mg single dose; avoid in pregnancy (first trimester).
Mebendazole:
ο Children > 2 years, adults: 100 mg bid for 3 days
ο Repeat after 2 weeks; avoid in pregnancy (first trimester).
☂
Prevention:
Education about personal hygiene, short fingernails
7.1.2. Trichuris trichiura (whipworm)
•
•
•
•
•
Most common in small children (dirtier habits; eating of dirt); in areas with
warm, humid climate
Often due to fertilizing fields (e.g. salad) with faeces
Can be associated with entamoeba histolytica – , ascaris – or hookworm
infections or shigellosis.
Can lead to exacerbation of other parasitic infections.
Size: 3-4.5 cm; colour: white or pink
Transmission:
Ingestion of food contaminated with soil containing eggs of trichuris
trichiura
♻
Life cycle:
Infective embryonated eggs are ingested, hatch in the intestine.
Adult worms live in large bowel feeding on tissue juices.
103
Parasitic Diseases
✎
Most infections: asymptomatic
In heavily infected patients:
ο Diarrhoea with blood; no fever
ο Right iliac fossa pain, epigastric pain, rectal prolapse
ο Iron deficiency anaemia
ο Growth retardation
Diagnosis:
Eggs in faeces
Clinical manifestations (rectal prolapse with worms)
Treatment:
Mebendazole:
ο Children > 2 years, adults: 100 mg bid; avoid in pregnancy (first
trimester)
Albendazole:
ο Children < 2 years: 200 mg od
ο Children > 2 years, adults: 400 mg od; avoid in pregnancy (first
trimester)
ο Less effective than mebendazole
☂
Prevention:
Safe disposal of human faeces (use of latrines)
Advice regarding personal hygiene
Education regarding careful washing of vegetables and fruit
7.1.3. Ascaris lumbricoides (roundworm)
•
•
•
•
104
Most common in childhood (children > 2 years), less in adulthood
Mainly in countries with poor sanitation
Often co-infection with other parasitic diseases
Size: 20-40 cm; pink or white
Parasitic Diseases
Transmission:
Ingestion of water or food (raw vegetables, fruit) contaminated with
eggs of A. lumbricoides
Occasionally via inhalation of contaminated dust
♻
Life cycle:
Eggs are passed with faeces, mature in the soil, are ingested with
infected food, hatch in the bowel as infective larvae.
Larvae penetrate the bowel wall, migrate via blood stream to the lungs
where they perforate the alveoli to get access to bronchi and trachea;
they move up to the epiglottis and are swallowed.
Mature worms live in the small intestine.
✎
Lungs:
ο Cough, wheeze, dyspnoea, pneumonia
ο Eosinophilia (on migration of larvae through the lungs)
ο Settling spontaneously
Bowel:
ο Recurrent colic, distended abdomen
ο Occasionally signs of obstruction (due to high worm load, volvolus
or intussusception) with severe infection
With migrating worms:
ο Obstructive jaundice, appendicitis, pancreatitis (esp. after fever or
anaesthetics)
ο Abscesses (e.g. in liver) or granulomas (peritoneum)
Infection with ascaris can be a contributing factor to malnutrition and
vitamin A deficiency.
Partial immunity can be acquired.
Diagnosis:
Eggs in faeces
Treatment:
Albendazole:
ο Children > 2 years, adults: 400 mg single dose; avoid in pregnancy (first trimester).
105
Parasitic Diseases
☂
Mebendazole:
trimester)
With signs of obstruction or acute abdomen: refer to hospital for
surgical intervention.
Pulmonary symptoms (self-limiting):
ο Treat with bronchodilators or oral steroids as required.
ο Anthelminthic therapy should preferably be given after settling of
pulmonary symptoms (to avoid problems caused by dying larvae).
Prevention:
Education regarding hygiene e.g. washing hands before meals
Advice to boil water before drinking
7.1.4. Ancylostoma duodenale (hookworm)
•
•
•
•
High prevalence in Asia, Africa; Necator americanus predominant in
Middle and South America, Africa, southern Asia
Grows well in warm, humid climate (can also exist in Europe, e.g. in
mines).
Usually affected: adults e.g. farmers who defecate on the fields; also
children affected in areas with poor sanitation (no latrines), esp. when
walking with barefoot
Size: about 1 cm; white, grey or red (from ingested blood)
Transmission:
Penetration of larva through intact skin or
Ingestion of food contaminated with eggs
♻
106
Life cycle:
Eggs are passed with faeces, hatch in the damp soil.
End stage infective larvae penetrate intact skin and migrate via
bloodstream to the lungs; here they break through the alveoli, move
up the bronchi and trachea to the oesophagus where they are
swallowed.
In the small intestine they change into adult worms and attach to the
mucosa sucking blood.
Parasitic Diseases
✎
Pruritus at entry-site with vesicles and pustules (ground itch)
Asthma, bronchitis: cough, wheeze, fever, eosinophilia (with lung
passage of worms)
Hypochromic, microcytic anaemia (esp. A. duodenale):
ο Pallor, tiredness, dyspnoea, oedema (due to loss of protein,
cardiac failure)
ο Esp. if severe infection and/or insufficient iron intake
Epigastric pain, occasionally melaena
Failure to thrive
Diagnosis:
Iron deficiency anaemia (exclude other causes of iron loss)
Eggs in faeces (may be negative in the early stages of the infection)
Treatment:
Albendazole:
ο Children > 2 years, adults: 400 mg single dose; avoid in pregnancy (first trimester)
Mebendazole:
trimester)
Elementary iron (adjust dosage according to available preparation e.g.
ferrous sulphate : elementary iron 3 : 1)
ο Children: 5 mg/kg od
ο Adults: 120 mg od
ο Duration of treatment: 3 months
ο Inform about dark stools, stomach upsets etc. (side effects of
therapy).
Folic acid:
ο Children > 1 year, adults: 5 mg od
ο Duration of treatment: 1 month
Advice regarding iron-rich food
107
Parasitic Diseases
☂
Prevention:
Advice to wear sandals or shoes
Advice regarding hygiene, cleanliness and sanitation
7.1.5. Strongyloides stercoralis (threadworm)
•
•
•
♻
Mainly in warm humid areas, but also in mines in colder climate
Immunity develops after primary infection.
Size: 2 mm
Life cycle:
Adult worms in bowel produce eggs which hatch in the bowel (internal
sexual cycle) into non-infective larvae; these are passed with the faeces.
In damp soil they develop into adults and reproduce (external sexual
cycle).
Infective larvae can develop; they penetrate the skin, travel via blood
stream to the lungs and break through the alveoli to gain access to
bronchi and trachea; they are swallowed and pass into the small bowel
where they develop into adult worms.
Transmission:
Penetration of larvae living in contaminated soil
Autoinfection: non-infective larvae develop into infective larvae in the
bowel; they can re-infect the host by penetration of bowel or perianal
skin.
108
Dermal symptoms:
ο Pruritus and rash at site of penetration
ο Itchy weal (linear, on trunk, of short duration) with larvae moving
under the skin (larva currens)
ο Urticaria due to allergy in sensitized persons
Respiratory symptoms:
ο Cough and wheeze
ο Dyspnoea, haemoptysis
Abdominal symptoms:
ο Watery diarrhoea
ο Abdominal pain (often vague)
Parasitic Diseases
✎
Chronic infection possible (with autoinfection):
ο Usually asymptomatic
ο Occasionally recurrent episodes of fever
ο Sometimes mild pneumonitis resembling recurrent bacterial
pneumonia
ο Possible: severe respiratory illness e.g. obstructive pulmonary
disease (worse with steroids), acute respiratory failure
Severe infection (hyperinfection syndrome):
ο Immunocompromised patients or patients receiving steroids:
Larvae invade different organs of the body e.g. bowel wall, lymph
glands, liver, brain with resulting severe diarrhoea, malabsorption,
paralytic ileus, septicaemia, encephalitis, meningitis.
Diagnosis:
Larvae or adult worms in faeces
In disseminated strongyloides: larvae in sputum and different body
fluids e.g. peritoneal fluid
FBC: eosinophilia
Treatment:
Albendazole:
ο Children < 2 years: 200 mg bid
trimester)
ο Repeat treatment after 2 weeks.
Ivermectin:
ο Children > 15 kg, adults: 200 mcg/kg single dose
ο Repeat treatment after 2 weeks.
In disseminated disease (hyperinfection syndrome):
ο Children > 15 kg, adults: ivermectin 200 mcg/kg od
ο Repeat stool investigation after treatment.
ο Patients with severe illness, pregnant women: refer to hospital.
109
Parasitic Diseases
7.1.6. Taenia saginata, taenia solium (tapeworm)
•
•
Problem in areas with poor sanitation and where people traditionally eat
undercooked or raw meat
Size: 5-10 m
Transmission:
Taenia saginata: ingestion of raw or undercooked beef
Taenia solium: ingestion of raw or undercooked pork; cysticercosis
can develop after eating food contaminated with eggs or eating with
fingers contaminated with infected faeces.
♻
Life cycle:
Larvae encapsulated in meat (cysticerci) are eaten.
Cysts turn into worms with heads attaching themselves to mucosa.
Proglottids (segments: up to 2000, containing fertilized eggs) grow;
they are highly motile, detach themselves and are shed with the
faeces.
Eggs are swallowed by cattle, develop into invasive larvae and break
through the intestinal wall into the circulation; from there they are
carried to the muscle where they encapsulate into cysticerci.
✎
110
Taenia saginata:
ο Nondescript symptoms (”hunger pains”)
ο Rarely intestinal obstruction
Taenia solium:
ο Cysticercosis:
> Encystation of larvae in muscles, skin (subcutaneous tissue),
eye or brain with resulting calcification
> Extraneuronal cysticercosis: often asymptomatic
> Cerebral cysticercosis: epilepsy or signs of raised intracranial
pressure
Diagnosis:
Proglottids or eggs in stool
Cysticercosis: calcifications visible on x-ray
Parasitic Diseases
Treatment:
Taeniasis:
ο Praziquantel:
> Children, adults: 5-10 mg/kg single dose
ο Niclosamide:
> Children 11-34 kg: 1 g (2 tab) single dose
> Children > 34 kg: 1.5 g (3 tab) single dose
> Adults: 2 g (4 tab) single dose
> Tablets have to be chewed.
Cysticercosis:
ο Anthelmintic therapy not always necessary
ο Refer to hospital for assessment and possible treatment.
7.1.7. Schistosomiasis
Causative agents:
Schistosoma japonicum (Philippines)
Schistosoma haematobium (Africa)
Schistosoma mansoni (Africa)
Transmission:
Contact with water containing cercarial larvae (e.g. through washing,
swimming, working in rice fields)
♻
Life cycle:
Eggs are passed with faeces or urine.
Miracidium hatches and invades water snail as intermediate host
where it undergoes asexual replication.
Cercariae are released and penetrate human skin, undergo changes
and reach the liver where they mature into adult flukes.
Eggs pass into host tissues and are excreted.
Early reaction (swimmers’ itch, shortly after infection):
ο Puritic papular rash with erythema, oedema, eosinophilia
ο Rare in endemic areas
ο Resolves spontaneously after 10 days.
111
Parasitic Diseases
✎
Initial stage (4 weeks after penetration; immune complex disease):
ο Katayama fever:
> Mainly in children or young adults
> Can be severe with fever, urticaria, diarrhoea, hepatosplenomegaly, cough and wheeze, cachexia.
> Spontaneous recovery
> In S. japonicum: patients often have non specific symptoms.
Established infection (caused by granulomas due to retained eggs):
ο S. japonicum, mansoni:
> Liver fibrosis with hepatosplenomegaly and portal hypertension, ascites and bleeding from oesophageal varices
> Pseudopolyposis of colon with ulceration and bleeding
> Involvement of peritoneum (tumors) and skin (rash)
> Cerebral granulomas with symptoms of raised intracranial
pressure, development of epilepsy or focal neurological
symptoms
ο S. haematobium:
> Eggs in the bladder lead to granulomatous lesions (pseudopapillomata) with haematuria
> Complications: obstruction of ureters and obstructive uropathy
with hydronephrosis, hydroureter, kidney failure, calcification
of the bladder with chronic dribbling, bladder carcinoma,
kidney stones
> Ectopic lesions can occur in lung, liver, CNS.
Diagnosis:
History
Kato-katz-test (stained smear from stool; negative result does not
exclude infection)
Dipstick: blood in urine
Rectal biopsy; eggs in urine
Ultrasound (to check liver, kidneys, bladder)
CT- scan (if suspected central nervous or spinal cord involvement)
Treatment:
Katayama fever:
ο NSAIDs, e.g. ibuprofen:
> Children > 7 kg: 30 mg/kg in 3 divided doses
112
Parasitic Diseases
ο
☂
Prednisolone:
> If severe hypersensitivity reaction
> Children: 1 mg/kg od
> Adults: 40 mg od
ο Praziquantel: start 6-10 weeks after initial presentation (ineffective
in early infection).
S. japonicum:
ο Praziquantel:
> Children, adults: 60 mg/kg in 2-3 divided doses at least three
hours apart
> Can be given in pregnant and lactating women, preferably not
in the first trimester of pregnancy.
S. haematobium, mansoni:
ο Praziquantel:
> Children, adults: 40 mg/kg in 1-2 divided doses for 1 day
> Can be given in pregnant and lactating women, preferably not
in the first trimester of pregnancy.
ο Neurological disease:
> Praziquantel and glucocorticoids to counteract inflammatory
response due to treatment of praziquantel and to avoid
deterioration of neurological symptoms
Prevention:
Advice regarding hygiene and safe disposal of urine and faeces
•
•
•
•
•
Epigastric pain is often caused by helminths.
Adults can have worms too.
Children younger than 1 year have a very small risk of infection with
worms. It is therefore not necessary to deworm them on a regular base.
Stool investigations for worms or eggs should only be performed in
patients with treatment failure (exception: immunocompromised patients
with suspected strongyloides infection).
Treat all patients who may have worms even if reinfection can not be
prevented. Just reducing the worm load can improve the outcome for
patients.
113
Parasitic Diseases
•
•
•
•
•
•
Treatment can be repeated every 4-6 months.
If possible treat the whole family.
Pregnant women: do not give any treatment in the first trimester; later in
severe cases: give mebendazole or albendazole.
Always give advice regarding cleanliness, e.g. washing hands before
eating or preparing food, protecting food from flies, sanitation and use of
latrines.
Fingernails of children should be cut short to prevent dirt and worm eggs
accumulating underneath.
Give advice not to eat raw or undercooked meat or fish.
7.2. Filariasis
Causative agents:
Filariae (nematodes), e.g.:
ο Wuchereria bancrofti (tropics), Brugia malayi (East and South
East Asia, South India)
ο Onchocerca volvolus (South America, West Africa)
Transmission:
Wuchereria bancrofti, Brugia malayi: mosquito species (anopheline
mosquito, culex, aedes; night-biting)
Onchocerca volvolus: simulium species (day-biting)
♻
Life cycle:
Third stage larvae (infective forms) are transmitted through bites,
migrate to lymphatics, skin or deep tissues and develop into adults.
Females produce microfiliae which reach blood or skin.
They are taken up by the vector, develop into infective larvae.
Wolbachia (rickettsia): symbiotic; important for embryogenesis of filariae
114
Lymphatic filariasis (Wuchereria bancrofti, Brugia malayi):
ο Often asymptomatic in endemic areas
Parasitic Diseases
ο
✎
Acute:
> Recurrent bouts of fever, lymphangitis and lymphadenitis with
redness and pain over lymphatic vessels and enlarged, tender
lymph nodes
> Epididymo-orchitis
> Tropical pulmonary eosinophilia with cough and wheezing
ο Chronic:
> Hydrocele
> Chyluria (rare in B. malayi infections)
> Lymphoedema of legs: asymmetrical, non-pitting (elephantiasis)
Onchocerciasis (river blindness; rarely encountered in our projects;
infection with onchocerca volvolus):
ο Skin (microfiliae in the skin): pruritus, papular rash with secondary
infection, premature ageing of skin
ο Eye: keratitis, iritis with redness, irritation and photophobia,
corneal sclerosis leading to blurring of vision and blindness
Diagnosis:
Lymphatic filariasis:
ο Microfiliae in the blood (nocturnal blood sample required because
of marked nocturnal periodicity of infection)
ο Serological test (antigen test)
Onchocerciasis:
ο Skin snips
ο Eye examination (split lamp)
Treatment:
Symptomatic:
ο Anti-inflammatory drugs e.g. acetylsalicylic acid 600 mg tid-qid
(adults, children > 12 years) and/or
ο Antihistamines e.g. diphenhydramine:
> Children: 1-2 mg/kg tid prn
> Adults: 50 mg tid prn
Therapeutic:
ο Lymphatic filariasis:
115
Parasitic Diseases
>
ο
116
Mass chemotherapy (national program in endemic areas,
once a year):
− Diethylcarbamazine (DEC): children, adults: 6 mg/kg
single dose (side effects: initially headache, dizziness,
malaise, vomiting due to dying parasites; also localized
reactions e.g. lymphadenitis; treatment contraindicated in
onchocerciasis due to risk of severe allergic reactions)
plus
− Albendazole (children > 2 years, adults): 400 mg single
dose
> Individual patient:
−
Doxycycline 100 mg bid for 4 weeks (treatment of
wolbachia; contraindicated in pregnant women, children
< 12 years); problem: long duration of treatment and resulting lack of compliance
followed by
− Ivermectin (if available): children, adults: 200 mcg/kg
single dose
or
− Diethylcarbamazine 6 mg/kg single dose
− Both drugs are given to eradicate microfilariae.
− Advice regarding:
Cleanliness: washing with soap and water, cutting of
toenails
Elevation of affected limb at night
Immediate treatment of infected wounds or abrasions
Onchocerchiasis:
> Mass chemotherapy (national program in endemic areas,
once a year):
− Ivermectin: children, adults: 200 mcg/kg single dose
> Individual patient:
− Ivermectin: if available; children, adults: 200 mcg/kg
single dose, repeat after 6-12 months if symptoms recur.
Parasitic Diseases
7.3. Leishmaniasis
Causative agents:
Leishmania species: transmitted by the bite of female Phlebotomus
sandflies (biting at dawn and dusk and during the night)
Reservoir: animals e.g. foxes, dogs etc.
Distribution:
Cutaneous leishmaniasis (oriental sore):
ο Old world: Mediterranean, Middle East, North Africa, Bangladesh
to East India
ο New world: Northern South America, Central America
Visceral leishmaniasis (kala-azar): Mediterranean Basin, East Africa,
India, Bangladesh, Brazil
Depending on the patient’s cell-mediated immunity
Cutaneous leishmaniasis:
ο Old world:
> Single or multiple itchy nodules (“oriental sore”) on inoculation
site (face, neck, arms, legs)
> Later with central crust and ulcer (with raised edges), healing
spontaneously after weeks or months and leaving a
depressed hypopigmented scar
> Wet forms develop rapidly, with lesions along the draining
lymphatics.
> Usually lifelong immunity, but recurrence possible in patients
with impaired immunity
ο New World:
> Often bleeding ulcers; chiclero’s ulcer (in men collecting latex
in the forests): located on the pinna of the ear, with chronic
infection and invasion of cartilage leading to destruction of
pinna
> Lymphatic and lymph node involvement common
Mucocutaneous leishmaniasis:
ο New World:
> Metastatic lesions develop up to 10 years after the
appearance of an ulcer on the skin.
117
Parasitic Diseases
>
>
✎
Initial lesion: nodule, usually in the nose
First sign: nasal obstruction or epistaxis, leading to destruction of nasal septum, uvula, pharynx and larynx
> Occasionally protruberant nose and mouth due to hypertrophy
(espundia = sponge)
Visceral leishmaniasis (kala-azar):
ο Fever, hepatomegaly, splenomegaly
ο Lymphadenopathy, pancytopenia
ο Severe weight loss; can cause cachexia.
ο In India: hyperpigmentation of skin, esp. of face, hands, body
(”kala-azar” = black sickness)
ο Intercurrent infections, bleeding
ο If untreated death in 80-90% of patients
ο Opportunistic infection: 70% of patients also infected with HIV
Diagnosis:
Cutaneous leishmaniasis: split skin smear (Giemsa staining)
Visceral leishmaniasis:
ο Serology e.g. ELIZA
ο Isolation of parasites from spleen, bone marrow or lymph nodes
Treatment:
Cutaneous leishmaniasis, Old world:
ο Paromomycin ointment
Cutaneous leishmaniasis (New world), mucocutaneous and visceral
leishmaniasis:
ο Refer to hospital for assessment and further treatment, e.g. with
sodium stibogluconate, amphothericin B or miltefosin.
Think of leishmaniasis if a patient presents with a persistent ulcer on face,
neck or arms.
7.4. Malaria
•
•
•
118
Most important of all tropical diseases
High morbidity and mortality
Distribution: tropical and subtropical areas
Parasitic Diseases
Causative agents:
Plasmodium falciparum: malaria tropica, predominantly Sub-Saharan
Africa
Plasmodium vivax, Plasmodium ovale: tertian malaria
Plasmodium malariae: quartan malaria
Transmission:
Bite of infected female anopheline mosquito (sporozoites in the saliva
of the mosquito)
Mother-to-child transmission (transplacentally)
Transmission through blood transfusion
♻
Life cycle:
Multiplication: schizogony (asexual multiplication) in humans,
gametogony (sexual multiplication) in female anopheles mosquito
Schizogony (asexual multiplication):
ο With bite of mosquito sporozoites are injected in the blood stream.
ο Tissue schizogony:
> 30 minutes post infection they enter liver cells, divide into preerythocytic schizont, containing merozoites.
> Possible: dormant stage of sporozoite in liver (= hypnozoite;
plasmodium vivax, ovale), awaking at a set time
> When mature, schizont releases merozoites into the blood
stream (after 5-12 days).
ο Blood schizogony:
> Merozoites enter red cells, develop into trophozoites, then into
schizonts which rupture releasing merozoites in the blood
stream.
> P. falciparum, vivax, ovale: blood schizogony completed in
48h
> P. malariae: blood schizogony completed in 72 h
> P. vivax, ovale, malariae: schizogony in the circulating blood
> P. falciparum: schizogony in capillaries deep in the body –
therefore rarely seen in the peripheral blood; also: cytoadherence of parasitized erythrocytes to endothelial surfaces
leading to large numbers of parasites in deep tissues
119
Parasitic Diseases
Release of parasites to the blood stream coincides with bouts of fever but
there is often no periodicity.
Gametogony (sexual multiplication):
ο Merozoites develop into gametocytes (male and female) inside
the red cells.
ο If swallowed by a mosquito they develop further into micro- and
macrogametes; these unite and, after several stages, produce
sporozoites which migrate to the salivary glands of the mosquito.
120
Incubation period:
ο P. falciparum: 7-30 days
ο P. vivax, ovale: about 2 weeks, but can take several months up to
several years (due to hypnozoites)
ο P. malariae: about 2-4 weeks
nd
rd
Fever: recurrent (often no periodicity such as every 2 or 3 day),
with rigors, hot stage and sweating stage
Anaemia (haemolytic); severe in P. falciparum
Splenomegaly
Jaundice
Vomiting, diarrhoea (DD: gastroenteritis)
Cerebral malaria with delirium, disorientation, convulsions, stupor,
coma
Renal failure, occasionally with oliguria, haemoglobinuria (Blackwater
fever: due to intravascular haemolysis)
Pulmonary oedema
Hypoglycaemia: esp. at risk: children, pregnant women
Disseminated intravascular coagulation
Severe disease mainly due to infection with P. falciparum
Recrudescence (recurrent attacks in untreated malaria due to
persistent blood forms):
ο P. falciparum: recurrent attacks over one year, then no further
attacks
ο P. malariae: recurrent episodes for up to 30 years
ο P. vivax, ovale: relapsing fever over several years (true relapse
due to hypnozoites in the liver)
Malaria in pregnancy:
ο Higher rate of miscarriage and stillbirths due to placental
insufficiency
Parasitic Diseases
ο
Risk of maternal death with severe malaria due to hypoglycaemia
and pulmonary oedema (increased risk of developing severe
malaria during pregnancy, esp. during the first pregnancy)
ο Increased risk of anaemia
ο Babies: low birth weight
ο Occasionally congenital malaria
Malaria in children:
ο High risk: children < 5 years
ο Fever, malaise
ο Anorexia, diarrhoea, vomiting
ο Coma, convulsions
ο Lactic acidosis, hypoglycaemia
ο Severe anaemia
Immunity:
Mainly in P. falciparum infections
Due to development of IgG cell-mediated immunity and antitoxic
immunity
Frequent re-exposure to infection is required (therefore higher risk of
acquiring an infection after longer exposure-free interval).
✎
Diagnosis:
Thick film with Giemsa stain – to be taken at least three times at
intervals; may be negative (even with severe disease) because of
sequestration of parasites in the deep capillaries
Note:
A positive film does not necessarily prove that the symptoms of the patient are
due to malaria (parasitaemia even in asymptomatic patients in endemic areas);
consider other diseases as well, e.g. typhoid fever.
Rapid diagnostic test (RTD):
ο Test for detection of specific antigens of plasmodium falciparum,
vivax or ovale
ο Sensitivitiy 40-95% (with > 100 parasites per μl blood; comparable
to experienced microscopist)
121
Parasitic Diseases
ο
ο
ο
Problems: test not resistant to heat; false negative results; result
remains positive for up to 3 weeks, even after successful
treatment.
No replacement for thick film
Use before starting stand-by treatment.
Always treat patients with suspected malaria even with negative RTD as there
is a possibility of a false negative result.
Treatment:
It is of utmost importance to check the current national guidelines and local
drug resistance when treating patients for malaria.
122
Supportive treatment:
ο Sponge with tepid water.
ο Rehydration (see chapter Dehydration, p.89)
ο Monitor renal output, blood glucose and haemoglobin and treat
accordingly.
ο Treat convulsions or other complications.
Specific treatment:
ο Chloroquine:
> Should only be used in areas with partial or no resistance to
plasmodium falciparum or in patients with quartan or tertian
malaria.
> Important: correct dose (narrow therapeutic margin)!
> Adults:
− 600 mg PO stat (4 tab at 150 mg)
− 300 mg at 6 hours
− 300 mg on day 2 and 3
> Children:
− 10 mg/kg PO stat
− 5 mg/kg at 6 hours
− 5 mg/kg on day 2 and 3
− If vomiting: same dose can be given IM, but avoid in
children < 6 years or < 15 kg
> Drug resistance to chloroquine: 3 types according to WHO:
− R 1: disappearance of parasite under treatment within 7
days, but relapse
Parasitic Diseases
ο
ο
ο
− R 2: noticeable fall without disappearance of the parasite
− R 3: no reduction of parasite level in spite of treatment
Quinine (with chloroquine resistance):
> Adults:
− Loading dose: 20 mg/kg IV, then 10 mg/kg tid IV or IM
(IM: 1 mL = 300 mg; IV: 1 mL = 60 mg; IVI: give in
5% glucose to counteract hypoglycaemia due to quinine)
− Change to oral medication as soon as possible: 600 mg
tid (2 tab at 300 mg) and add: doxycycline 100 mg bid.
> Children:
− Loading dose 20 mg/kg, then 10 mg/kg tid IV or IM (give
IV medication in 5% glucose)
− Change to oral medication as soon as possible: 30 mg/kg
in 3 divided doses.
− Duration of treatment: 7 days minimum
Mefloquine (with relapse: rising trophozoites, rising temperature;
no vomiting):
> Adults:
− 750 mg PO (3 tab at 250 mg) stat
− 500 mg after 6 hours
− If body weight > 60 kg: 250 mg after another 6 hours
> Children (≥ 6 months, > 5 kg):
− 15 mg/kg PO (max. 750 mg) stat
− 10 mg/kg after 6-12 hours (max. 500 mg)
> If no clinical improvement within 48-72 hours use alternative
therapy for retreatment.
> Avoid in pregnant patients and patients with neuropsychiatric
disorders (e.g. depression, convulsions).
Primaquine:
> In India and the Philippines
> For eradication of hypnozoites
> If diagnosis of tertian malaria is confirmed, low risk of
reinfections and good compliance of patient
> Adults: 15 mg PO od
> Children: 0.25 mg/kg PO od
> Important: test for glucose-6-phosphate-dehydrogenase deficiency before starting treatment to avoid risk of haemolytic
anaemia
123
Parasitic Diseases
ο
☂
124
Artemisinine:
> Only in combination with other drugs e.g.
> Artemether 20 mg + Lumefantrin 120 mg (Riamet ® or
Coartem®)
− Adults, children ≥ 16 years, ≥ 35 kg):
4 tab PO stat, then at 8 hours, 24 hours, 36 hours, 48
hours, 60 hours (total 24 tablets over 60 hours)
− Children (2 months to < 16 years, WHO recommendations):
5-14 kg: 1 tab PO stat, then at 8 hours, 24 hours, 36
hours, 48 hours, 60 hours (total 6 tablets over 60
hours)
hours)
hours)
> Treatment in pregnancy:
− If malaria is suspected refer to hospital immediately.
− WHO treatment recommendations:
First trimester: quinine plus clindamycin PO for 7 days
Second and third trimester: artesunate (first line
treatment; can be given PO or IV), artemether
(second line treatment; can be given PO or IM)
Avoid mefloquine (study in Thailand: higher rate of
stillbirths)
Contraindicated: primaquine, doxycycline
Prevention:
Advice regarding protective clothing, esp. in the evening (light long
clothes)
Use impregnated mosquito nets and/or curtains if available.
Infectious Diseases
8. INFECTIOUS DISEASES
8.1. Dengue Fever Syndromes
Causative agent:
RNA-virus, 4 serotypes
Transmission:
Human to human by bites of Aedes aegypti mosquito which flies
during the day
8.1.1. Dengue fever
•
•
•
•
Widespread in Asia, esp. South-East Asia, Western Pacific; also Central
and South America
Dramatic increase in transmission worldwide
Mainly children affected as most adults are immune to locally existing
serotypes
Long lasting immunity develops to the infecting serotype, short lived
immunity to the other serotypes.
✎
Symptoms more severe in older children and adults
High fever, occasionally biphasic
Relative bradycardia
Severe headache, pain behind the eyes, photophobia
Myalgia (severe: break bone fever), arthralgia
Anorexia
Rash: maculo-papular, erythematous; generalized, later: petechial
with scattered pale patches over arms, hands, legs, feet (“white
islands in a red sea”)
Generalized lymphadenopathy
Haemorrhagic complications possible e.g. epistaxis, bleeding from
gums, haematuria
Diagnosis:
Leucopenia
125
Infectious Diseases
Occasionally thrombocytopenia
Treatment:
Symptomatic with painkillers e.g. paracetamol
Avoid aspirin (risk of bleeding)
8.1.2. Dengue haemorrhagic fever (DHF), dengue shock syndrome
(DSS)
•
•
In infants and children under the age of 16 years, after previous infection
with different serotype causing dengue fever
Pathophysiological changes: increased vascular permeability leading to
leakage of plasma and haemoconcentration
✎
High fever, acute onset, continuous for 2-7 days
Anorexia, abdominal pain, vomiting
Haemorrhagic manifestations: petechiae, ecchymosis, bleeding from
nose and gums, haematemesis, melaena
Hepatomegaly
Dengue shock syndrome: critical stage at end of febrile period:
ο Cold clammy skin, restlessness
ο Signs of shock (rapid weak pulse, hypotension, narrow pulse
pressure)
ο Possible: oedema, pleural effusion, ascites
Diagnosis:
3
Thrombocytopenia (thrombocytes < 100 000/mm )
Haemoconcentration: rise in haematocrit by 20% above average for
age and sex
Treatment:
Supportive treatment e.g. antipyretics (avoid aspirin)
Refer to hospital for fluid replacement:
ο If shock start IVI with Ringer’s Lactate solution or normal saline at
10-20mL/kg over 20 minutes; repeat prn once or twice until vital
126
Infectious Diseases
ο
ο
ο
signs (pulse, blood pressure) and haematocrit improve, then
reduce.
Check blood sugar (?hypoglycaemia); if hypoglycaemia give
dextrose 10% 5 mL/kg.
Avoid excessive fluid replacement.
Treatment usually necessary for 24-48 hours
8.2. Leprosy
Causative agent:
Mycobacterium leprae (Hansen bacillus)
Transmission:
Human-to-human (probably droplet infection or infection from ulcers)
Initial infection often asymptomatic, occasionally resolving spontaneously
Lepromatous leprosy (people with low resistance, widespread
bacillary infiltration):
ο Diffuse infiltration with thickening of skin; maculo-papular lesions,
can be hypopigmented or erythematous
ο Nerve thickening leading to bilateral and symmetrical sensory and
motor dysfunction with paraesthesia, hyperaesthesia, hyperalgesia,
also muscle wasting leading to paralysis
ο Nasal infiltration with discharge and ulceration
ο Infiltration of eyes (iritis, corneal changes leading to blindness),
testes (atrophy), lymph nodes (swelling, ulceration)
Tuberculoid leprosy (people with good resistance, few bacilli,
localized):
ο Skin: few lesions (macules), hypopigmented or red, sharply
demarcated, with sensory loss; destruction of hair follicles
ο Nerve thickening with early sensory loss; palpable thickening e.g. of
ulnar, median or peroneal nerve; asymmetrical
127
Infectious Diseases
✎
Diagnosis:
Clinical manifestations: palpable thickening of nerves (e.g. sulcus of
elbow), sensory loss
Slit-scrape smear of skin
Lepromin test (for classification and prognostic purposes; negative in
lepromatous leprosy)
Treatment:
Refer to hospital or local treatment program.
8.3. Measles (Morbilli)
•
•
One of the most common childhood infectious exanthems
A major killer in childhood: higher mortality rate in developing countries,
esp. when associated with malnutrition and vitamin A deficiency (”do not
count your children until the measles have passed”)
Causative agent:
Paramyxovirus
Transmission:
Spread by droplets
128
Incubation period: 7-10 days
th
Infectious period: from the 8 day of the incubation period until 5 days
after onset of rash
Severe illness
Catarrhal phase with fever, runny nose, conjunctivitis, cough and
Koplik’s spots (red spots with bluish-white center on buccal mucosa)
for 2-3 days
Rash (maculo-papular) for 4-5 days (difficult to recognize in dark skin)
Complications:
ο Respiratory:
> Bronchopneumonia (risk of activating underlying tuberculosis)
Infectious Diseases
ο
ο
ο
ο
ο
ENT:
> Otitis media
> Laryngitis (often with stridor)
Gastrointestinal:
> Diarrhoea with risk of dehydration and malnutrition
> Stomatitis, also with thrush and herpes leading to problems
eating or sucking
Ophthalmological:
> Conjunctivitis with risk of corneal ulceration and keratomalacia
leading to blindness, esp. in patients with vitamin A deficiency
Persistent pyrexia with severe rash (black measles) and
desquamation
Rarely encephalitis (with residual brain damage)
Treatment:
Treat fever with tepid sponging and paracetamol.
Keep eyes wet and clean; antibiotic eye ointment (e.g. tetracycline 1%
eye ointment).
Give vitamin A:
ο Patients without sign of vitamin A deficiency:
> Children < 6 months: 50 000 IU day 1 and 2
> Children 6 to 12 months: 100 000 IU day 1 and 2
> Children > 1 year, adults (unless women of childbearing age):
200 000 IU day 1 and 2
ο Patients with sign of vitamin A deficiency (e.g. Bitot’s spots,
corneal ulceration, keratomalacia):
> Children < 6 months: 50 000 IU day 1, 2 and 8
> Children 6 to 12 months: 100 000 IU day 1, 2 and 8
> Children > 1 year, adults (unless women of childbearing age):
200 000 IU day 1,2 and 8
Keep well hydrated and nourished.
ο Continue breastfeeding.
ο In case of diarrhoea: give
> ORS (see chapter Dehydration, p.89)
> Zinc supplements:
− Children < 6 months: 10 mg od
− Children 6 months to 5 years: 20 mg od
− Duration of treatment: 14 days
129
Infectious Diseases
☂
Antibiotics (high doses, esp. for patients with high risk of complications or death e.g. severely malnourished children, patients with
HIV-infection):
ο Erythromycin:
> Adults: 500 mg tid-qid or
ο Amoxicillin:
> Adults: 1000 mg tid
Follow-up:
ο If cough: think of tuberculosis
ο Regular weight control and check-ups (Road to Health Chart);
advice regarding extra meals
ο Give vitamin A if not yet done.
Prevention:
rd
Immunization: from the age of 9 months to 12 years and up to the 3
day post incubation (during the first 6 to 9 months the baby is
protected by maternal antibodies; therefore immunization may not be
effective)
•
•
It is of utmost importance to check the immunization status regarding
measles and immunize if not yet done.
Treatment with vitamin A can significantly reduce morbidity (esp. the
risk of blindness) and mortality in children with measles.
8.4. Meningitis
• Often epidemic in developing countries with meningococci type A and C as
causative agents
• Outbreaks esp. during dry season, mainly in Sub-Saharan Africa (Burkina
Faso to Tanzania)
130
Infectious Diseases
• More often in people living in poor conditions (low income, poor housing),
esp. in children in slums
Causative agents:
Bacterial: mainly meningococcus, pneumococcus (often with other
focus e.g. pneumonia), Haemophilus influenzae; rarely: E. coli,
staphylococcus, Group B streptococcus, salmonella, listeria; also:
Mycobacterium tuberculosis
ο In newborns mainly: Group B streptococcus, enterococcus,
listeria, E. coli, klebsiella
ο Children > 2 months: meningococcus, pneumococcus, Haemophilus influenzae B
ο Adults: meningococcus, pneumococcus; with impaired immunity:
pathogens similar to those in newborns
Viral: ECHO-virus, coxsackie, mumps, polio, herpes
Depending on causative agent
Bacterial:
ο Pyrexia (sudden onset)
ο Headache, backache, nausea
ο Neck stiffness: Brudzinski and Kernig’s signs positive (lying
patient involuntarily flexes the knees when the neck is flexed or
when the legs are raised vertically with knees in extension)
ο Babies and small children: often nonspecific signs e.g. inability to
drink, drowsiness, convulsions; bulging fontanelle
ο Old people, alcoholics: initially often fever, confusion
ο Tuberculous meningitis: gradual onset, headache, drowsiness;
later: convulsions, cranial nerve involvement e.g. diplopia, ptosis
Viral:
ο Acute onset
ο Occasionally signs of underlying disease e.g. parotitis, paralysis
with poliomyelitis
Complications:
ο Waterhouse-Friedrichsen’s-Syndrome:
> Fulminant meningococcal septicaemia with purpuric rash due
to haemorrhages in skin and mucosa, renal failure
(haemorrhage into the adrenal cortex), shock
> Often fatal despite treatment
131
Infectious Diseases
ο
Surviving patients may have long-term neurological problems e.g.
deafness, spasticity, mental retardation, epilepsy, speech impairment.
✎
Cerebral malaria
Typhoid fever
Consider underlying cause of meningitis e.g. sinusitis, otitis media,
head injury, endocarditis, pneumonia.
Diagnosis:
If meningitis is suspected start treatment straight away prior to hospital referral
for further investigations and treatment.
Lumbar puncture; if available ask for gram staining and direct
microscopy of cells
Cell count in the cerebrospinal fluid (CSF)
Treatment:
Give first dose prior to hospital transfer.
132
Infants < 2 months:
ο Ampicillin IM/IV: 50 mg/kg qid plus
ο Gentamycin IM/IV:
> First week of life: 3 mg/kg od with low birth weight; 5 mg/kg od
with normal birth weight
> After second week of life: 7.5 mg/kg od
Children > 2 months:
ο Oily chloramphenicol IM: 25 mg/kg qid plus
ο Ampicillin IV/IM: 50 mg/kg qid
Or, if available:
ο Ceftriaxone IV/IM: 100 mg/kg od
Adults:
ο Oily chloramphenicol IM: 100 mg/kg od (up to 3 g; if necessary
half of the dose in each side); avoid in pregnant women
Or, if available:
ο Ceftriaxone IV/IM: 2 g od
Infectious Diseases
Pregnant or breastfeeding women:
ο Ampicillin IV/IM: 2 g qid
Or, if available:
ο Ceftriaxone IV/IM: 2 g od
Duration of treatment depends on pathogen and underlying disease:
> Meningococcus: 7-10 days
> Pneumococcus, haemophilus: 10-14 days,
> Listeria: 4-6 weeks
The earlier meningitis is treated the better is the prognosis.
☂
Prevention:
Vaccine for meningococcal meningitis available (vaccine anti A, C, W
or Y; protection: 3 years); if there is an increase in patients with
meningitis in an endemic area mass vaccination should be started as
soon as possible.
8.5. Pertussis (Whooping Cough)
•
•
Can occur at any age.
High mortality, esp. in infants (no protection from maternal antibodies)
Causative agent:
Bordetella pertussis, spread by droplets
Incubation period: 6-20 days
Catarrhal phase with nasopharyngeal discharge and nonspecific
cough for 1-2 weeks
Whooping phase with paroxysmal cough (with subsequent vomiting)
and tenacious sputum for 6-8 weeks
Persistent cough only in about 50% of patients
Infants less than 3 months may develop sneezing fits and apnoeic
periods leading to cyanosis
Infectious period from 2 days before onset of cough; for 3 weeks
Complications:
ο Malnutrition due to loss of appetite and recurrent vomiting
133
Infectious Diseases
ο
ο
ο
Epistaxis, haemoptysis, subconjunctival haemorrhage
Bronchopneumonia
Encephalitis
Treatment:
Antibiotics (children):
ο Erythromycin 50 mg/kg in 3 divided doses for 2 weeks
Best if given in the catarrhal phase: can shorten the infective period and
can avoid complications e.g. pneumonia.
Maintain good fluid intake and encourage good nutrition.
☂
Prevention:
Immunization
8.6. Rabies
•
•
High risk in developing countries due to high prevalence of disease in
stray animals
Concerning our projects: mainly a problem in Kolkata, Bangladesh and the
Philippines
Causative agent:
Rhabdovirus
Transmission:
Saliva of infected animal, mainly bites of dogs but also cats, bats, wild
animals etc.
Inoculation possible before developing signs of illness (14 days for
cats, dogs)
Different types of exposure (WHO 2009):
Category I (no exposure):
ο Touching or feeding of animals
ο Licks on intact skin
Category II:
ο Minor scratches or abrasions without bleeding
ο Nibbling of uncovered skin
134
Infectious Diseases
Category III:
ο Single or multiple transdermal bites or scratches
ο Licks on broken skin
ο Contamination of mucous membrane with saliva from licks
ο Exposure to bat bites or scratches
Incubation period: 2 weeks to several months (up to 1 year)
Rapid onset with fever, anxiety, pain and paraesthesia at the side of
bite; insomnia
Painful spasms of throat muscles, hydrophobia
Later: widespread paralysis, respiratory arrest
With the onset of clinical symptoms: death inevitable (due to
meningoencephalitis with neuronal destruction)
Treatment:
Symptomatic disease:
ο Refer to hospital or state-run animal bite center.
Treatment of wound:
ο Wash and flush bite and scratch wounds immediately with soap
and plenty of water (for about 15 minutes).
ο Apply antiseptic (e.g. Povidone iodine solution).
ο Postpone suturing if possible
ο Tetanus prophylaxis
Vaccination depends on type and condition of animal at time of bite
and after 10 days.
Avoid contact with patient’s saliva – it is potentially infective.
☂
Prevention:
Vaccination
Post-exposure vaccination (WHO 2010):
ο People without immunization or with
immunization:
> Category I:
− No vaccination necessary
incomplete
previous
135
Infectious Diseases
>
ο
ο
136
Category II:
− Immediate rabies vaccination: one dose IM on day 0, 3,
7, 14, 30 (adults: in deltoid muscle, children < 2 years.
anterolateral area of thigh); alternative: two doses IM on
day 0 (deltoid muscle, right and left arm), 1 dose on day 7
and 1 dose on day 21 (regimen 2-1-1)
− Immunocompromised patients: give additional immunoglobulin (see treatment for category III exposure).
> Avoid gluteal muscle (poor response!).
> Category III:
− Immediate rabies vaccine one dose IM (adults: in deltoid
muscle, children < 2 years: anterolateral area of thigh) on
day 0, 3, 7, 14, 30; alternative: two doses IM on day 0
(deltoid muscle, right and left arm), one dose on day 7
and one dose on day 21 (regimen 2-1-1)
plus
− Immunoglobulin
(preferably
human
rabies
immunoglobulin HRIG 20 IU/kg, but often short supply;
otherwise equine rabies immunoglobulin ERIG 40 IU/kg;
small risk of hypersensitivity reactions) as much as
possible infiltrated around the wound, the rest to be given
IM at a site distant from vaccine administration (e.g. into
anterior thigh).
Give immunoglobulin preferably at, or as soon as possible after
the initiation of post-exposure vaccination. It is not indicated
beyond the seventh day (by then active antibody response to
vaccination has probably ocurred).
Immunized patients after exposure:
> Rabies vaccine: as soon as possible one dose IM day 0 and 3
> Immunocompromised patients (e.g. HIV-patients): give full
post-exposure prophylaxis.
Infectious Diseases
Prophylaxis of rabies after exposure:
Nature of exposure
Prophylaxis
Category I:
Touching or feeding of animals
Licks on intact skin
None
Category II:
Start vaccination immediately;
Minor scratches or abrasions without stop vaccination if animal is healthy after
bleeding
10 days or proven to be free of rabies by
Nibbling of uncovered skin
appropriate laboratory investigations.
Category III:
Single or multiple transdermal bites or
scratches
Licks on broken skin
Contamination of mucous membrane with
saliva from licks
Exposure to bat bites or scratches
Give immunoglobulin and start vaccination
immediately (see previous page);
stop vaccination if animal is healthy after
10 days or proven to be free of rabies by
appropriate laboratory investigations.
•
•
•
Even immunized people need post-exposure booster vaccination.
With treatment of wounds: do not forget tetanus prophylaxis or antibiotics
e.g. cefuroxime or erythromycin.
According to the latest guidelines of the WHO (2010) patients who
present for evaluation and rabies post-exposure prophylaxis even months
after having been bitten should be dealt with in the same manner as if the
contact occurred recently.
137
Diseases of the Urinary Tract
9. DISEASES OF THE URINARY TRACT
9.1. Urinary Tract Infection
Causative agent:
E. coli
✎
More common in women
Dysuria, lower abdominal pain
Frequent urination
Cloudy malodorous urine, occasionally haematuria
Fever: often in children, rarely in adults
Complications:
ο With ascending infection or spreading via bloodstream: fever,
chilling, lower abdominal pain, back or lumbar pain, cloudy urine,
often with blood
ο With recurrent infections: think of schistosomiasis, genitourinary
tuberculosis, lithiasis, gonorrhea.
ο In children: often presenting with fever, vomiting or failure to thrive
Diagnosis:
Dipstix: leucocytes positive, blood positive, nitrate positive
Beware of false positive results with dipstix examination, esp. with
leucocytes in women, therefore clinical picture must be taken into
consideration.
Treatment:
Paracetamol or aspirin for pyrexia
Acute uncomplicated cystitis:
ο Adults:
> Cotrimoxazole 960 mg (160 mg TMP + 800 mg SMZ) bid or
> Fluoroquinolone e.g. ciprofloxacin 250 mg bid; avoid in
pregnancy.
ο Pregnant women:
> Amoxicillin 500 mg tid for 7 days
138
Acute complicated cystitis, acute pyelonephritis:
ο Adults:
> Cotrimoxazole 960 mg (160 mg TMP + 800 mg SMZ) bid or
> Fluoroquinolone e.g. ciprofloxacin 500 mg bid
ο Children > 2 months:
> Cotrimoxazole 8 mg/kg TMP + 40 mg SMZ in 2 divided doses
or
> Cefuroxime 30 mg/kg in 2 divided doses
ο Infants < 2 months:
> Refer to hospital (risk of renal complications).
ο Pregnant women:
> Referral to hospital
With recurrent infections:
ο Ciprofloxacin:
> Adults: 500 mg bid; avoid in pregnancy.
recommended for children as yet but use if benefit outweighs
the risk.
ο Pregnant women: amoxicillin 500-1000 mg tid for 10 days
9.2. Acute Glomerulonephritis
•
•
•
After otherwise benign streptococcal infection (pharyngitis, impetigo)
Auto-immune inflammation of the glomeruli, occurring after 1-5 weeks
Mainly in children over 3 years of age and adults
Proteinuria, haematuria
Hypertension, occasionally with encephalopathy
Oedema
Treatment:
Bed rest during the acute stage
Low salt diet
139
Antibiotics for underlying streptococcal infection:
ο Children:
> Penicillin V 50 mg/kg in 3-4 divided doses or
> Erythromycin 50 mg/kg in 3 divided doses
ο Adults:
> Penicillin V 500 mg qid or
> Erythromycin 500 mg qid
Furosemide (with oedema):
ο Children: 1 mg/kg single dose; if required can be given in up to tid.
ο Adults: 40 mg up to tid
ο Adapt dose according to clinical response.
Treat hypertension.
9.3. Nephrotic Syndrome
•
Increasing prevalence due to increasing number of patients with diabetes
mellitus and hypertension
Causes:
Glomerulonephritis
Diabetes mellitus
Quartan malaria
Plasmocytoma
Amyloidosis
✎
140
Severe proteinuria (> 3 g/24 h)
Hypoalbuminaemia (< 30 g/l)
Oedema
Hyperlipidaemia
Later: hypertension
Uncomplicated cases: often good prognosis with improvement after
steroid treatment or spontaneous resolution
Diagnosis:
History (?underlying disease)
Urine dipstick (protein +++)
Serum creatinine, electrolytes
FBC, blood glucose
24- hour urine collection for 24- hour protein
Renal ultrasound
With suspected underlying malaria: blood smear for malaria parasites
Treatment:
Rest
First manifestation:
ο If possible refer to hospital for further investigations and treatment
e.g. diuretics, ACE-inhibitors, prednisolone (for minimal change
glomerulonephritis) and diet advice.
Therapeutic options in adults:
ο Diuretics:
> In severe cases: Furosemide: 40 mg up to 3 times/day
ο ACE-inhibitors e.g.
> Enalapril: 10-20 mg od
> Ramipril: 2.5-5 mg od
ο Diet:
> Low protein diet (protein restriction to 0.8-1 g/day; high protein
diet leading to deterioration of renal function)
> Not necessary in patients with mild renal failure (glomerular
filtration rate > 25 mL/min)
> Patients with advanced renal failure: only supervision of diet
necessary as they take little protein anyway due to poor
appetite
> Low salt diet and restricted water intake (with higher urine
production more fluids can be given)
Therapeutic options in children:
ο Furosemide
ο Prednisolone: can be useful in children, esp. with minimal change
glomerulonephritis, but should be started by specialist;
tuberculosis must be ruled out before patient is started on long
term steroids.
141
Sexually Transmitted Diseases/HIV
10.
SEXUALLY TRANSMITTED DISEASES/HIV
10.1. Sexually Transmitted Diseases (STD)
•
People particularly at risk of contracting sexually transmitted diseases:
commercial sex workers, their clients, bar workers, military, truck drivers,
sailors, policemen
Important in taking a history:
Privacy (if possible)
Avoidance of moralistic attitude
Questions to ask:
ο Nature and duration of symptoms
ο Drugs already taken
ο Sexual history
ο Previous medical history
ο Female patients: menstrual/obstetric history
Information about HIV important
Difficult: differential diagnosis, esp. without being able to investigate
appropriately (no microscope, no speculum)
10.1.1. Gonorrhoea
Causative agent:
Neisseria gonorrhoeae
142
Males:
ο Urethritis with dysuria
ο Thick yellow discharge
ο With ascending infection: fever, prostatitis, epididymitis (unilateral)
ο Urethral stricture
Females:
ο Fewer symptoms
ο Urethritis, dysuria, vaginal discharge
ο With ascending infection to uterus, fallopian tubes: endometritis,
salpingitis; also pelvic inflammatory disease (PID) with fever and
abdominal pain; later: increased risk of ectopic pregnancy,
infertility
Disseminated gonorrhoea:
ο Arthritis
ο Dermatitis, purulent conjunctivitis
ο Endocarditis
Ophthalmia neonatorum:
ο In newborns of mothers infected with gonorrhoea
ο Bilateral purulent conjunctivitis
ο Perforation and scarring of cornea, leading to blindness
Treatment:
Gonorrhoea in adults:
ο See syndromic approach p.149, p.152
Ophthalmia neonatorum:
ο Treatment:
> Ceftriaxone: 50 mg/kg IM single dose (maximum 125 mg)
> Give also to infants born to mothers with gonococcal
infections.
> All newborn infants with conjunctivitis: add
− Erythromycin syrup 50 mg/kg in 4 divided doses
− Treatment for N. gonorrhoeae and C. trachomatis
> No need to give additional eye drops
ο Severe cases: refer to hospital for IV penicillin.
ο Prevention:
> Tetracycline eye 1% ointment to both eyes
10.1.2. Chlamydial infection
•
•
Often co-infection with gonorrhoea, but longer incubation period
Both sexes affected
Causative agent:
Chlamydia trachomatis
143
Often asymptomatic
Symptoms similar to gonorrhoea
Males: urethritis
Females: vaginal infection; ascending infection leading to pelvic
inflammatory disease with risk of ectopic pregnancy or infertility
Infection of the newborn: conjunctivitis, pneumonia
Treatment:
Chlamydial infection in adults:
ο See syndromic approach p.152
Infection of the newborn (suspected chlamydial infection):
> Erythromycin syrup 50 mg/kg PO in 4 divided doses for 14
days and
> Ceftriaxone: 50 mg/kg IM single dose (maximum 125 mg; see
treatment ophthalmia neonatorum p. 143)
10.1.3. Syphilis
•
•
High seroprevalence in developing countries, esp. in Africa (50%), South
America (10%), Asia (5-10%)
Primary chancre: often not recognized; resolves spontaneously
Causative agent:
Treponema pallidum (spirochaetes)
10.1.3.1. Primary syphilis
144
Incubation period: 2-3 weeks; infective stage of disease
Painless, indurated moist papule with clean base and raised edge
(primary chancre)
Mainly on the glans, foreskin, shaft of penis
Diagnosis often missed in women (most common on the cervix,
occasionally on the labia)
Inguinal lymphadenopathy (hard, painless)
After 4-6 weeks: painless ulcer, resolving over several weeks
✎
Diagnosis:
Dark field microscopy: spirochaetes
Serology negative
10.1.3.2. Secondary syphilis
✎
Infective stage; 2-3 months after infection
Non-itching macular, papular or pustular rash, often desquamating;
esp. on palms, soles; occasionally whitish areas on mucosa of mouth,
vagina, penis
Generalized lymphadenopathy
Condylomata lata in moist areas of the body
Systemic illness with fever and malaise
Alopecia
Rarely meningism, optic neuritis
Resolving after several weeks (in one third of cases; afterwards: latent
stage; one third of patients: tertiary syphilis)
Diagnosis:
TPHA (T. pallidum haemagglutination): specific test, used for
screening
FTA (fluorescent treponemal antibodies): for confirmation of diagnosis
VDRL (veneral disease reference laboratory): nonspecific; used to
monitor response to treatment
10.1.3.3. Tertiary syphilis
Gumma: granulomatous lesions with local tissue destruction mainly
affecting skin, bones, mucous membranes (manifestation after 3-10
years)
Cardiovascular disease (about 10%) with aneurysm of the ascending
aorta, aortic valve disease, coronary ostial occlusion (30-40 years
after infection)
Disease of the central nervous system (about 6%) with ataxia,
progressive paralysis, dementia (20-30 years after infection)
145
10.1.3.4. Congenital syphilis
•
•
Congenitally infected children of mothers with primary or secondary
syphilis
Higher rate of stillbirth or neonatal death
Rash with desquamation, esp. palms, soles
Persistent nasal discharge
Anaemia, hepatosplenomegaly
Periostitis of long bones with pseudoparalysis
Later in life (> 6 years): Hutchinson’s trias: keratitis, dental abnormalities, sensory deafness
Treatment:
Syphilis in adults:
ο See syndromic approach p.150
Congenital syphilis:
ο Refer to hospital for treatment with antibiotics.
ο Investigate and treat mother and her sexual partner.
10.1.4. Chancroid (soft sore)
•
•
Most common cause of genital ulceration in Africa increasing the risk of
HIV infection
Causative agent:
Haemophilus ducreyi
146
Painful soft ulcer, bleeding on contact; often multiple
Painful inguinal lymphadenopathy, occasionally with fistula formation
or local destruction
Resolves spontaneously within 1 year.
Primary syphilis
Herpes simplex
Lymphogranuloma venereum
Treatment:
See syndromic approach p.150
10.1.5. Lymphogranuloma venereum (LGV)
Causative agent:
Chlamydia trachomatis
Initially small painless genital ulcer, often unrecognized, resolving
spontaneously
Second phase: painful lymphangitis, lymphadenitis with inguinal
lymphadenopathy (buboes)
Fever, malaise
Chronic infection leading to genital elephantiasis, abscess formation,
fistula, rectal and sigmoidal stenosis
Treatment:
10.1.6. Trichomoniasis
Causative agent:
Trichomonas vaginalis
Males normally asymptomatic, but infectious
Females:
ο Yellow-green frothy discharge, getting less in the later stages of
the disease
ο Urethritis with dysuria
ο Pain in vulva, vagina
147
Treatment:
10.1.7. Vulvovaginal candidiasis
Causative agent:
Candida albicans
Pruritus of vulva, vagina
Vaginal discharge (whitish)
Treatment:
10.1.8. Genital herpes
Causative agent:
Herpes simplex virus type 2 (HSV 2)
Vesicles, later ulcers, crusting over and resolving
On external genitalia, urethra, cervix
Pain (occasionally severe, causing constipation and retention of
urine), dysuria
Tender lymphadenopathy
Primary attack lasting for up to 3 weeks
Subsequent attacks (occasionally up to 12/year) resolving faster
High neonatal mortality if child is infected with herpes from mother
Treatment:
Treatment:
In our projects according to the syndromic approach
148
Check for 6 cardinal symptoms:
ο Urethral discharge
ο Vaginal discharge
ο Genital ulcer
ο Lower abdominal pain
ο Inguinal bubo (painful swelling of lymph nodes)
ο Scrotal swelling
Advantages of syndromic approach:
ο Treatment is possible straight away without waiting for results.
ο Treatment of co-infections
ο Simple diagnostic methods have low sensitivity anyway.
Always remember when treating patients:
4 C’s: Counselling, Compliance, Condoms, Contact-treatment
Always use drugs available in the respective project.
Urethral discharge (male):
Gonorrhoea
Chlamydial infection
Treatment:
Ciprofloxacin 500 mg single dose
Plus
Doxycycline 100 mg bid for 7 days
or
Azithromycin 1 g single dose
or
Amoxicillin 500 mg tid for 7 days
or
149
Erythromycin 500 mg qid for 7 days
Persistent or recurrent symptoms of urethritis:
ο Possibly due to drug resistance, poor compliance, re-infection
ο In some cases: Trichomonas vaginalis infection:
> Try metronidazole 500 mg PO bid for 7 days.
ο Persistent symptoms: refer to hospital.
Vaginal discharge:
Candida albicans
Bacterial vaginosis (Gardnerella vaginalis + Mycoplasma hominis)
Treatment:
Metronidazole 2 g single dose (can also be given in pregnancy if
benefits outweigh the risk)
Plus
Clotrimazole vaginal pessary 500 mg single dose or 200 mg for 3
days
Genital ulcers:
Syphilis
Chancroid (Haemophilus ducreyi)
Granuloma inguinale
Lymphogranuloma venereum (LGV)
Genital herpes
Note:
If patients present with genital ulcer it is very important to establish a working
diagnosis and treat according to main symptoms.
If there is no improvement after 7 days refer for investigations.
150
Treatment:
Suspected primary or secondary syphilis:
ο Benzathine Benzyl Penicillin 2.4 million units (2 x 1.2 million units)
IM single dose or
ο With allergy against penicillin and not pregnant:
> Doxycycline 100 mg PO bid for 2 weeks
ο With allergy against penicillin and pregnant:
> Erythromycin 500 mg PO qid for 2 weeks
Suspected late syphilis (more than 2 years of infection):
ο Benzathine Benzyl Penicillin 2.4 million units IM once weekly for 3
weeks or
ο With allergy against penicillin and not pregnant:
> Doxycycline 100 mg PO bid for 30 days
ο With allergy against penicillin and pregnant:
> Erythromycin 500 mg PO qid for 30 days
Plus
Suspected chancroid:
Ciprofloxacin 500 mg bid for 3 days
or
Erythromycin 500 mg qid for 7 days
or
Suspected granuloma inguinale add instead:
or
Doxycycline 100 mg bid
or
Erythromycin 500 mg qid
Continue treatment until lesions are completely epithelized.
151
If no improvement suspect genital herpes and give:
Acyclovir 400 mg tid for 7 days
Lower abdominal pain (female):
Emergencies (if rebound tenderness or guarding: refer to hospital):
ο Appendicitis
ο Ectopic pregnancy
ο Pelvic abscess
STD e.g.
ο Gonorrhoea
ο Chlamydial infection
ο Infection with anaerobic bacteria
Gynaecological referral of patients with:
Pregnancy
Delayed last menstrual period
Recent delivery or abortion
Menorrhagia
Fever
Treatment for suspected STD:
Plus
Doxycycline 100 mg bid for 2 weeks
Plus
Metronidazole 400 mg bid for 2 weeks
Review after 3 days; without improvement: refer to hospital.
152
Scrotal swelling:
Under 35 years of age, sexually active: STD e.g.
ο Gonorrhoea
ο Chlamydial infection (with discharge)
Over 35 years of age:
ο Other infection of testis or epididymis e.g. due to E. coli, Klebsiella, Pseudomonas, TB etc.
Prepubertal:
ο Infection with E. coli, Pseudomonas
ο Mumps
Testicular torsion: sudden onset of scrotal pain (refer for surgeryemergency!)
Trauma
Tumor
Treatment:
Suspected STD: treat for gonorrhoea:
Plus
Doxycycline 100 mg bid for 7 days
or
Inguinal bubo:
(Swollen inguinal or femoral lymph nodes, possibly fluctuant)
Lymphogranuloma venereum (LGV)
Chancroid
Non-STD (local infection of lower limbs, tuberculosis)
153
Treatment:
Ciprofloxacin 500 mg bid for 3 days
or
Doxycycline 100 mg bid for 2 weeks
or
Erythromycin 500 mg qid for 2 weeks
10.2. HIV
•
•
•
•
•
•
154
AIDS Epidemic Update 2009: global epidemic still stable at high level, but
number of people living with HIV/AIDS (PLWHA) increasing with ongoing
number of new infections and more widely available antiretroviral therapy
At present:
• Worldwide: 33.4 million people living with HIV, 2.7 million new
infections (48% young people aged 15-24 years) and 2.0 million HIVrelated deaths; 2.0 million children younger than 15 years were
infected.
• Sub-Saharan Africa: most heavily affected (67% of people living with
HIV; 72% of all HIV-related deaths); Kenya: estimated 1.5 to 2 million
people living with HIV
• Asia: 4.7 million people living with HIV, 330 000 deaths from HIVrelated illnesses; people living with HIV (estimates 2008): India: 2.4
million, Philippines: 8300, Bangladesh: 12 000
• Latin America: 2.0 million people living with HIV (Nicaragua 7700;
estimate 2007), 77 000 deaths from HIV-related illnesses
25 million deaths up to 2007
Numbers often estimates due to difficulties in reporting rates in some
countries
Additional problems of stigma and discrimination encountered by people
living with HIV
HIV epidemic leading to reduced life expectancy, increased household
poverty and reduced economic growth in the most heavily affected
countries
Special problems in developing countries:
Sub-Saharan Africa: HIV transmission mainly during heterosexual
intercourse; other regions: mainly infection of certain risk groups
(commercial sex workers, intravenous drug users, men having sex
with men)
Equal numbers of men and women affected, but number infected
women has increased in many regions
Risk of mother-to-child transmission high (without intervention: 2548%)
Often blood products not checked for HIV or problems with window
period
Treatment often not affordable
Causative agent:
HI-virus (retrovirus)
Transmission:
Highest viral concentration in blood, semen, vaginal secretion; esp. in
the first weeks after acute infection or with symptomatic disease
No transmission in everyday life; no spread by droplets of sputum
Mainly transmitted by sexual contact (heterosexual, homosexual)
ο 0.1-0.5% risk of infection with unprotected intercourse
ο Risk of infection enhanced by
> Presence of sexually transmitted diseases: 2-9 fold increased
risk of transmission (STD with and without an ulcer)
> Use of desiccating vaginal agents e.g. herbs
Mother-to-child transmission during pregnancy, delivery or breastfeeding
Blood products (~95% risk of infection): problem with window period
(no antibodies found with recent infection)
Contaminated syringes: in less than 5% cause of transmission; less
relevant in developing countries
Several stages:
ο Primary infection or acute retroviral illness:
> Not all patients affected
> 2-4 weeks after exposure, self-limiting
155
156
> Fever, malaise, headache, lymphadenopathy
> Diarrhoea, nausea, skin rashes
> Seroconversion after 3 months
ο Asymptomatic HIV-infection:
> Viral replication, but clinical latency
> Gradual decline of T-helper cells
> Lasting for up to 10 years before break-down of immune
system
> Period may be shorter in developing countries.
ο Symptomatic HIV-infection/AIDS:
> Destruction of immune system due to increasing destruction
of T-helper cells
> Weight loss, weakness, lymphadenopathy
> Additional opportunistic infections and neoplasms (increasingly common and severe)
> Strong correlation with tuberculosis (10% risk per year for
people living with HIV)
> Untreated leading to death (one third of all deaths due to
tuberculosis)
WHO Clinical Staging of HIV/AIDS for Adults and Adolescents:
ο Stage 1:
> Asymptomatic
> Persistent generalized lymphadenopathy
ο Stage 2:
> Moderate weight loss (< 10% of body weight)
> Minor mucocutaneous manifestations (seborrhoeic dermatitis,
prurigo, fungal infection, recurrent oral ulcerations, angular
cheilitis), herpes zoster, past or recurrent within last 2 years
> Recurrent upper respiratory tract infections (bacterial sinusitis,
bronchitis, otitis media, pharyngitis)
ο Stage 3:
> Severe weight loss (> 10% of body weight)
> Unexplained chronic diarrhoea > 1 month
> Unexplained prolonged fever > 1 month
> Oral candidiasis
> Oral hairy leucoplakia (OHL)
> Pulmonary tuberculosis (PTB) in past year
> Severe bacterial infections (e.g. pneumonia, pyomyositis,
empyema, bone or joint infections)
ο
ο
✎
Stage 4:
> HIV wasting syndrome
> Pneumocystis jiroveci pneumonia (PCP)
> Recurrent severe bacterial pneumonia (at least 2 episodes
within 1 year)
> Cryptococcal meningitis and extrapulmonary cryptococcosis
> Cerebral toxoplasmosis
> Chronic orolabial, genital or ano-rectal herpes simplex infection for > 1 month
> Kaposi’s sarcoma (KS)
> HIV encephalopathy
> Extrapulmonary TB (EPTB)
> Crytosporidiosis with diarrhoea > 1 month
> Isosporiasis
> Disseminated non-tuberculous mycobacterial infection
> Cytomegalovirus (CMV) retinitis or disease of the organs
(other than liver, spleen or lymph nodes)
> Progressive multifocal leucencephalopathy (PML)
> Any disseminated endemic mycosis (e.g. histoplasmosis)
> Candidiasis of oesophagus or airways
> Non-typhoid salmonella (NTS) septicaemia
> Cerebral lymphoma or B-cell non-Hodgkin lymphoma (NHL)
> Invasive cervical cancer
> Visceral leishmaniasis
Different clinical stages for children
Diagnosis:
At present testing only done in our project in Nairobi
Tests:
ο Rapid test (Determine Immunoassay)
nd
ο With positive test: confirmation with 2 rapid test (Bioline)
Problems:
ο No antibodies in the early stages (diagnostic window)
ο Maternal antibodies are present in an infant for up to 20 months
without the child being infected
Further blood tests:
ο CD4 count
ο Full blood count (anaemia, neutropenia, thrombocytopenia)
157
Treatment:
In most projects: patients with suspected HIV need to be referred to
specialized hospitals.
HIV-treatment by “German Doctors for Developing Countries” only in
the HIV-project in Nairobi:
ο Counselling and testing:
> VCT: voluntary counselling and testing: for asymptomatic
patients
> DCT: diagnostic counselling and testing: for symptomatic
patients with possible HIV infection
> RCT: routine counselling and testing for pregnant women
ο Continuous, comprehensive outpatient care for people living with
HIV/AIDS on different levels (medical, psychological, social and
nursing)
Example: Baraka Treatment and Care Program:
ο Medical treatment (follow-up program) for all patients (independent of HIV-stage):
> Cotrimoxazole for prevention of opportunistic infections
> Multivitamins
> Deworming
> Review every 1-3 months
> CD4 count every 6 months
ο Support group for HIV-positive patients, e.g.
> Regular meetings
> Memory Books
ο Feeding program
ο Home based care for bed-ridden patients
ο Prevention of mother-to-child-transmission (PMTCT):
> HIV-positive mothers:
− Regular CD4 counts
− Antiretroviral therapy according to national guidelines
> Infant intervention:
− Antiretroviral therapy including nevirapine according to
national guidelines
− Cotrimoxazole
− Feeding program after birth (formula milk; mothers
advised regarding hygiene)
158
ο
Highly Active Antiretroviral Therapy (HAART) according to nationnal guidelines:
> For patients with CD4 < 350 (stage 1,2,3) or stage 4 (irrespective of CD4) and proven compliance
> Before starting medication:
− Blood tests e.g. FBC, CD4 count, LFTs
− Assigning patient to community health worker and
“treatment buddy” supervising intake of medication
> Combination of at least 3 antiviral drugs e.g. Stavudine (D4T)
or AZT + Lamivudine (3TC) + Nevirapine
> Regular follow-ups with blood tests, attendance of support
group
Treatment of opportunistic infections if possible, otherwise referral
Post-Exposure-Prophylaxis (PEP) after exposure to blood or certain
body fluids of patient with possible HIV-infection:
ο Risk of transmission: 0.3% after percutaneous exposure to HIVinfected blood (possibly higher after exposure with large-bore
needle or high viral load)
ο Indication for HIV-PEP:
> Recommended after:
− Percutaneous injury with injection needle or other hollow
needle (high risk body fluids like blood, bloody body fluids,
CSF)
− Superficial injury (e.g. with surgical needle) if index patient
probably has high viral load, otherwise PEP should be
offered
− Contact with high-risk body fluids to mucous membranes
or non-intact skin
> Not recommended after:
− Percutaneous contact with other body fluids (e.g. urine,
saliva)
− Contact of intact skin with blood
− Contact of skin or mucous membrane with body fluids like
urine or saliva
ο Immediate treatment:
> Percutaneous injury: encourage bleeding, then rinse
thoroughly with alcohol-based antiseptic
> Contamination of non-intact skin: rinse thoroughly with > 80%
ethanol-based preparation (e.g. Frecaderm) + PVP-iodine
159
>
ο
ο
☂
160
Contamination of eye or mouth: rinse thoroughly with isotonic
watery PVP-iodine solution (eye: 2.5%, mouth: PVP-iodine
1:1 diluted)
> If antiseptic solutions not available: use water for immediate
rinsing of contaminated area
Medication:
> Start as soon as possible within 72 hours – preferably within 2
hours
> Prophylaxis with
− Combivir ® (lamivudine + zidovudin) 1 tablet bid +
Viracept ® (nelfinavir) 2 tablets bid or Combivir ® 1 tablet
bid + Kaletra ® (lopinavir + ritonavir) 3 tablets bid
− Duration of treatment: 4 weeks
− Blood tests: HIV-test (including index patient), hepatitis
serology; repeat after 6 weeks, 3 months and 6 months
Documentation of injury
Prevention:
Education of patients regarding avoidance of high risk behaviour and
use of condoms (best done by trained staff)
Prevention of mother-to-child-transmission through education and
medication
Treatment of sexually transmitted diseases
Reduction of blood transfusions in anaemic patients to the absolute
minimum:
ο Transfusions should only be given in life-threatening events. Even
for chronic anaemia with haemoglobin < 5 g/dl treatment with
ferrous sulphate and folate is sufficient.
ο Important: treatment and prevention of underlying conditions such
as hookworm infections, malaria, schistosomiasis, malnutrition,
pregnancy; avoid repeated Hb-checks!
•
•
•
•
•
No treatment of HIV/AIDS should be done without structured pre-test
and post-test- counselling.
It is of utmost importance to minimize risk of HIV-transmission when
handling possibly contaminated body fluids!
Always wear safety equipment e.g. gloves and goggles or gowns if
necessary.
Always dispose of sharps safely.
In case of injury: do not forget documentation of event.
161
Antenatal/Postnatal Care
11.
•
•
•
•
•
ANTENATAL/POSTNATAL CARE
In developing countries antenatal care aims to minimize complications
which threaten life and health of pregnant women.
In Africa: 700 maternal deaths due to pregnancy and delivery per 100 000
life births.
In Bangladesh 40% of teenage pregnancies have complications (e.g.
pregnancy-induced hypertension, eclampsia), in industrialized nations 1%.
In developing countries nearly all women are anaemic before getting
pregnant; in 50% of pregnant women the haemoglobin is less than 8.5 g%.
In some projects we have antenatal programs with standardized checks
which have to be performed by the doctors; in other projects we refer to
official programs.
11.1. Antenatal Checks
Time of antenatal check-up:
WHO recommendations:
ο With uncomplicated pregnancies: 4 check-ups during pregnancy
(8- weekly intervals):
> 9-13. week (to estimate date of delivery)
> 18-22. week
> 28-32. week
> On the estimated date of delivery
History:
Past/present medical history: ?diseases leading to complications during pregnancy
Gynaecological/obstetric history: ?problems during previous pregnancies and deliveries (assessment of risk)
Estimation of date of delivery:
st
1 day of last period plus 7 days minus 3 months
Abdominal palpation:
Try to find out how the baby is lying.
Women with breech presentation or transverse lie have to be sent to
hospital for delivery.
162
Weight check:
Usual weight gain during pregnancy: 8-10 kg
Risk of insufficient weight gain due to malnutrition and poverty
Sudden weight gain due to generalized oedema: sign of complications
(eclampsia)!
Fetal movements:
Only 40% of fetal movements (“kicks”) felt by mother
Primipara: first fetal movements felt at 20 weeks’ gestation
Multipara: first fetal movements felt at 18 weeks’ gestation
Reduction of fetal kicks below 5 per day: start Daily Fetal Movement
Count (DFMC):
ο Mother counts fetal kicks starting at the same time every morning
recording starting time and end of counting; count stops after 10
kicks.
ο Short version: mother counts fetal kicks over 3 hours, then
multiplies number by 4.
ο Normal pregnancy: more than 10 kicks in 12 hours
ο Pathological (sign of placental insufficiency): less than 10 fetal
movements in 12 hours; refer to gynaecologist
Urinalysis (dipstick):
Proteinuria:
ο Pre-eclampsia: > 0.3 g/24 hours in urine (dipstick: ++)
ο Severe pre-eclampsia: > 0.5 g/24 hours in urine (dipstick: +++)
Bacteriuria:
ο Higher risk of cystitis or pyelonephritis in pregnancy
ο Important: screening of asymptomatic women for leucocytes,
blood and nitrate in the urine and subsequent treatment of women
with positive results
Glycosuria:
ο Possible sign of gestational diabetes (sensitivity 30%)
ο If pregnant woman has family history of diabetes mellitus,
delivered babies with high birth weight (> 4.5 kg) in the past or if
diabetes mellitus is suspected: check blood glucose; arrange oral
glucose tolerance test (if woman is seen during our own antenatal
checks, otherwise refer).
163
Blood pressure check:
Hypertension (systolic ≥ 160 mmHg, diastolic ≥ 100 mmHg)
ο Treatment with methyldopa: start with 250 mg bid, increase if
necessary (maximum 3 g daily dosage).
Hypotension (systolic < 100 mmHg, diastolic < 60 mmHg)
ο Can occur when patient is lying on the back (pressure of uterus on
veins and vena cava).
ο Advice to lie on left side, increase fluid intake.
ο Ask for danger signs e.g. pain, bleeding; refer if necessary.
Give iron and folic acid:
Elementary iron: 60 mg od plus folic acid 0.8 mg od during the whole
pregnancy
Adjust dosage according to available iron preparation, (e.g. ferrous
sulphate : elementary iron 3 : 1).
Immunization status: complete tetanus immunization if necessary to
prevent neonatal tetanus.
11.2. Ectopic Pregnancy
•
•
•
•
Egg implants outside the uterine cavity.
Responsible for about 7% of maternal deaths
Increased risk after pelvic inflammatory infection, previous ectopic
pregnancy, endometriosis, tubal surgery, IUD in situ
97%: implantation in tubes
164
Abdominal pain; may be mild (without peritonism) in subacute
manifestation; can severe in acute manifestation (acute abdomen with
peritonism).
Vaginal bleeding (dark or fresh) – often after about 8 weeks of
amenorrhoea
Collapse, shock (with pallor, tachycardia, low blood pressure)
Occasionally shoulder tip pain
Palpation: ?adnexal mass
✎
Twisted ovarian cyst (no amenorrhoea, no vaginal bleeding)
Appendicitis (leucocytosis, fever)
Perforated gastric/duodenal ulcer
Diagnosis:
Pregnancy test positive
Ultrasound scan:
ο Tubal/abdominal mass
ο Empty uterus
Think of an ectopic pregnancy in:
Fertile women with lower abdominal pain associated with continuous
vaginal bleeding
Fertile women with collapse
Always take a gynaecological history.
Treatment:
ο Set up IV infusion e.g. Ringer’s Lactate solution.
ο Refer to hospital straight away.
11.3. Pre-Eclampsia
•
•
•
•
One of the most serious complications in pregnancy
In industrialized countries: in 5-10 % of pregnancies, higher incidence in
developing countries
nd
rd
Usually in the 2 and 3 trimester
Mainly primigravidae and women > 35 years affected
Oedema
Proteinuria
Hypertension
Can progress to eclampsia:
ο Headache, visual disturbance
ο Confusion
ο Tonic-clonic seizures, coma
165
ο
Renal failure, pulmonary oedema
Note:
With vomiting, abdominal pain and tenderness over the liver: think of HELLPsyndrome (haemolysis, elevated liver enzymes, low platelets.
Refer to hospital immediately (life-threatening condition).
Treatment:
Long term treatment:
ο Methyldopa PO: initially 250 mg bid - tid, increase gradually at
intervals of at last 2 days prn (up to 3 g/day); usual dose: 2501000 mg/day in 2 divided doses
Emergency treatment (severe pre-eclampsia):
ο Hydralazine 5 mg diluted in 10 mL 0.9% normal saline IV every
20 minutes (maximum 30 mg; side effects: tachycardia,
headache) or
ο Nifedipine caps 5 mg PO, repeat after 20 minutes if required
(avoid first trimester)
Refer to hospital for intensive treatment.
Magnesium sulphate: although used commonly in developed
countries it does not seem to be an option in the field due to risk of
side effects and difficulties in administration.
Criteria for admission to hospital:
Hypertension: systolic BP ≥ 160 mmHg or diastolic BP ≥ 100 mmHg
rd
Proteinuria and weight gain > 1 kg/week in the 3 trimester
Suspected HELLP-syndrome
Reduced fetal kicks
Suspected IUGR (intrauterine growth retardation)
Additional findings: pre-existing maternal illness (renal, diabetes
mellitus), multiple pregnancy, early gestational age (before 34. week),
oligohydramnios
166
11.4. Antepartum/Postpartum Haemorrhage
11.4.1. Antepartum haemorrhage
•
•
th
Vaginal bleeding after the 28 week and before birth of the child
Main causes: abruptio placentae, placenta praevia, ruptured uterus
Abruptio placentae:
ο Often without contractions
ο Blood loss can be concealed – therefore the condition can be far
more serious than assumed from the amount of blood actually
seen.
ο Patient can be in pain.
ο Shock
Placenta praevia:
ο Previous medical history: often recurrent episodes of painless
vaginal bleeding in pregnancy (esp. during the last 12 weeks)
ο Severe haemorrhage during labour with dilatation of cervix
Ruptured uterus:
ο Esp. in patients with previous medical history of caesarian section
and with obstructed labour or after numerous pregnancies
ο Abdominal pain
ο Shock
ο Life threatening event for mother and baby
Treatment:
Check blood pressure and heart rate.
Set up IV infusion: large IV cannula (16 G); if in shock give Ringer’s
Lactate solution 1-3 litres IV; if available give gelafundin 30-40 mL/kg
IV.
Refer to hospital.
With antepartem haemorrhage:
Never perform a vaginal examination as this can cause severe bleeding.
Always refer to hospital as soon as possible!
167
11.4.2. Postpartum haemorrhage
•
•
•
•
Excessive vaginal bleeding after delivery
Main causes: vaginal tear, cervical tear, placenta accreta, atonic uterus
Blood loss difficult to assess as the blood is mixed with amniotic fluid and
is lost in towels, linen etc.
Normal blood loss: 200-300 mL; postpartum haemorrhage: > 500 mL
Placenta accreta:
ο Placenta not separating from myometrium of uterus
Atonic uterus
ο Inefficient uterine contraction/retraction after separation of
placenta
ο Fundus soft, high (normally: uterus postpartum firm, fundus at the
level of umbilicus)
ο Haemorrhage can be severe.
Treatment:
Check blood pressure and heart rate.
Set up IV infusion: large IV cannula (16 G); if in shock give Ringer’s
Lactate solution 1-3 litres IV; if available give gelafundin 30-40 mL/kg
IV.
Placenta accreta:
ο Give oxytocin 10 IU IV in 500 mL of Ringer’s Lactate solution.
ο Send patient to hospital for manual removal of placenta.
Atonic uterus:
ο With patient lying on her back rub uterus gently with one hand:
place fingers behind the fundus, thumb in front of the fundus.
ο Give oxytocin 10 IU IV in 500 mL of Ringer’s Lactate solution.
ο If no success: bimanual compression of uterus:
> Right hand inserted into the vagina, formed into a fist and
placed in anterior fornix of vagina pressing against the
anterior wall of the uterus.
> Left hand placed on the abdomen behind the uterus pressing
downwards to press the posterior wall of the uterus against
the anterior wall.
ο Last resort: compression of aorta:
> One fist pressing downward into the abdomen just above the
umbilicus, slightly to the left.
168
>
Other hand palpating femoral pulse: if still palpable compression is insufficient and further pressure needs to be
applied until bleeding is controlled.
With postpartum haemorrhage:
Every patient must be sent to hospital immediately for further management.
11.5. Mastitis
•
•
•
Usually caused by staphylococci.
Predisposing factors: nipple erosion, poor emptying of breast
Non-lactating women: think of other causes e.g. carcinoma.
Sore, cracked nipple
Part of the breast hot, red, swollen
Lymphadenopathy, occasionally fever
Occasionally abscess
Treatment:
Start as soon as possible to avoid abscess formation.
Breastfeeding should be continued (shorter, but more often) if at all
possible unless there is a severe infection; baby should feed from
affected breast first.
Clean nipples with boiled cool water.
Gently rub breast milk on the nipples after feeding.
Severe infection: express breast milk for a few days.
Antibiotics PO:
ο Cloxacillin 500 mg qid or if penicillin allergy:
ο Erythromycin 500 mg qid
ο Duration of treatment: 7-10 days
Cool compresses
Abscess: trial of antibiotics; if no improvement: refer for surgical
intervention.
169
Skin Problems
12.
SKIN PROBLEMS
12.1. Skin Rashes
12.1.1. Allergic rashes
•
•
Can be caused by exposure to certain allergens e.g. special food, food
additives, drugs (e.g. penicillin).
Other causes: intestinal parasites e.g. helminths, viral infection (e.g.
URTI), hepatitis, auto-immune disease
✎
Urticaria
Maculo-papular rash
Diagnosis:
Investigation according to possible underlying cause
Non-allergic rashes e.g. due to
ο Syphilis
ο HIV
ο Viral disease
ο Typhoid fever
Treatment:
Clean affected areas with cool water.
Calamine lotion to stop the itch
Chronic rash:
ο Zinc paste tid or
ο Hydrocortisone 1% ointment tid (only for a short period of time
e.g. 10 days)
Pruritus:
ο Diphenhydramine:
> Children: 1-2 mg/kg tid prn
If possible treat underlying cause.
Advice to avoid exposure to allergens e.g. drugs, certain food etc.
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Skin Problems
12.2. Dermatitis/Eczema
12.2.1. Allergic contact dermatitis
•
Caused by allergens e.g. perfumes, metals, chemicals, food or plants,
rove or blister beetles (Nairobi eye)
12.2.2. Irritant contact dermatitis
•
•
Exposure to irritants e.g. water, heat, chemical substances, cement, tar
Affects men working without personal protective equipment or women with
long-term exposure to water and manual work (laundry, cooking).
Acute:
ο Redness, vesicles, blisters, pustules (with infection)
Chronic:
ο Papules, lichenification, scaling
ο Painful fissures
ο Atrophy of skin
Treatment:
Eczema with redness:
ο Hydrocortisone 1% ointment tid to affected areas
Superinfected eczema:
ο First povidone iodine solution 10% tid or gentian violet solution
0.5% tid
Sensitive skin:
ο Vaseline or coconut oil
Advice to avoid exposure to sensitizing agents
Advice regarding use of personal protective equipment or change of
work if at all possible
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Skin Problems
Nairobi eye:
ο Compresses with mild antiseptic solutions (e.g. gentian violet
0.5%)
ο Steroids e.g. prednisolone only in severe cases
12.3. Atopic Eczema
•
•
•
Hereditary condition
Often combined with allergic asthma or hayfever or allergy to certain food
e.g. vegetables, herbs, fruit, nuts etc.
Exacerbations often brought on by stress, illness etc.
Babies:
ο Hyperkeratotic plaques on head (cradle cap)
Smaller children:
ο Eczema with redness and tiny blisters
ο Often on cheeks and ears
Older children:
ο Hyperkeratotic plaques and papules (lichenification), erosions,
crusts, fissures
ο Mainly in flexures of knees and elbows, sides of neck, arms, hand,
feet
Adults:
ο Mainly isolated patches of eczema, esp. on lower legs and
forefeet with pruritus, hyperpigmentation and lichenification (lichen
simplex chronicus)
Severe itch; secondary infection possible
Treatment:
Cold compresses to itchy lesions
Exposure to sunlight can be beneficial.
Dry lesions:
ο Ichthammol ointment 20% or zinc oxide ointment tid
ο Hydrocortisone 1% ointment tid for several days
For prevention of superinfection:
ο Hydrocortisone 1% cream at night and
ο Povidone iodine solution 10% in the morning
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Skin Problems
Superinfected eczema:
ο Gentian violet solution 0.5% or povidone iodine solution 10% for
treatment of infection
If pruritus:
ο Diphenhydramine:
> Children 1-2 mg/kg tid prn
Advice to cut children’s finger nails short to stop them from scratching;
in babies it might be necessary to cover their hands with gloves or
socks.
12.4. Bacterial Infections
12.4.1. Impetigo
•
•
•
•
Highly contagious
Often recurrent episodes
Affects mainly children
Complications e.g. renal involvement or rheumatoid arthritis more
common in developing countries
Causative agents:
Streptococci
Staphylococci
Mainly small, occasionally large fragile blisters, later with pus; yellow
crusts
Often associated with skin damage
Lesions located especially around the mouth.
Complications:
ο Spread over body affecting hair roots esp. in face and on head
causing boils and abscesses
ο Rheumatic fever or acute glomerulonephritis (if caused by streptococci)
Slight itchiness
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Skin Problems
If located on the head: exclude head lice.
If mainly nocturnal itchiness all over the body and involvement of other
family members: exclude scabies.
Treatment:
Wash affected areas several times a day with warm water and soap.
Gentian violet solution 0.5% or povidone iodine solution 10% to
affected areas
In extensive cases (3-4 lesions present, abscess, boils):
ο Cloxacillin:
> Duration of treatment: 1 week
ο Erythromycin:
> Adults: 500 mg tid-qid
ο Cefuroxime:
> Adults: 250-500 mg bid
Advice to keep the affected child away from other children.
Advice regarding cleanliness
Treat underlying conditions e.g. headlice, scabies.
12.4.2. Abscess
•
•
Caused by puncture wound or infected hair root
Bacteria can spread after rupture of affected hair follicle or with blood
stream leading to collection of pus in cutaneous and subcutaneous tissue.
Localized swelling, erythema, warmth, tenderness
Later: fluctuance
Treatment:
Hot compresses repeatedly to affected area
Ichthammol ointment 20% locally
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Skin Problems
Larger fluctuant abscesses: incision and drainage
Antibiotics in case of systemic infection e.g.
ο Erythromycin:
ο In severe cases:
> Cloxacillin:
− Children: 50 mg/kg in 3-4 divided doses
− Adults: 500-1000 mg qid
− Duration of treatment: 1 week
− To be taken on an empty stomach
or if available
> Cephalosporines e.g. cefuroxime:
− Children: 30 mg/kg in 2 divided doses
− Adults: 250-500 mg bid
12.4.3. Erysipelas/cellulitis
•
•
After minor trauma or other breaks in the skin
Common site of entry for bacteria: interdigital space of feet after fungal
infection; also insect bites
Risk factors:
Immunodeficiency
Diabetes mellitus
Alcohol/drug abuse
Anaemia
Lymphoedema
Obesity
12.4.3.1. Erysipelas
•
Infection spreads in dermis and upper subcutaneous tissues
Causative agent:
Group A ß-haemolytic streptococci
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Skin Problems
Mainly on face or legs
Red, hot, oedematous tender area of skin; sharply demarcated
Severe illness: vesicles, bullae, erosion
Accompanying lymphangitis
Fever and malaise
With recurrent episodes: fewer symptoms: mild erythema, persistent
oedema
12.4.3.2. Cellulitis
•
Spreading infection in dermis and epidermis
Causative agents:
Staphylococci
Group A ß-haemolytic streptococci
Often affected: lower legs
Mainly localized symptoms
Redness (less well demarcated), diffuse oedema, warmth, pain
Occasionally lymphangitis with adenopathy
Complications: abscess formation, purulent blisters, necrosis of soft
tissue, rarely necrotizing fasciitis
Treatment:
Immobilize affected limb.
Advice regarding cool compresses
Antibiotics PO:
ο Cloxacillin:
> Adults: 500-1000 mg qid
> To be taken on an empty stomach
or
ο Erythromycin:
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Skin Problems
or if available
ο Cephalosporines e.g. cefuroxime:
Severe infections: admit to hospital for IV antibiotics and possible
further intervention.
With fungal infection of the foot: clotrimazole ointment tid for 3-4
weeks
Check for underlying diseases and treat accordingly.
12.4.5 Tropical ulcer
•
•
Often in malnourished patients with low protein intake
Occurs after minor trauma e.g. insect bite, cut or abrasion.
Causative agents:
Bacillus fusiformis, spirochaetes
Mixed infections with other bacteria possible
Usually affecting ankle or lower leg
Initially papule or blister; develops rapidly into an ulcer and destroys
the surrounding tissue
Occasionally exposes muscles or tendons
Very painful in the beginning, pain decreases after about 4 weeks.
Healing slowly, but often becomes stationary at 1-10 cm in size
Painless in chronic state
Complications:
ο Infection of underlying bone or tendon
ο Septicaemia
ο Tetanus
ο Occasionally superinfection with diphtheria, leading to a white
membrane on ulcer
Tuberculosis
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Skin Problems
Leishmaniasis
Ecthyma (ulcerative bacterial infection caused by streptococci or
staphylococci)
Treatment:
Clean with povidone iodine solution or Ringer’s Lactate solution.
Daily dressings with povidone iodine ointment
Acute stage:
ο Penicillin V:
> Duration of treatment: 5-7 days
If no improvement give:
ο Erythromycin:
or if available
ο Cephalosporine e.g. cefuroxime:
Tetanus prophylaxis
Advice to wear shoes, if possible long trousers
12.5. Fungal Infections
12.5.1 Tinea (ringworm)
•
Endemic in areas with hot and humid climate, esp. in crowded and dirty
living conditions and close contact with animals
Causative agents:
Dermatophytes (living in stratum corneum of skin invading horn of hair
roots of body and scalp)
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Skin Problems
Tinea pedis (athlete’s foot), tinea manuum:
ο Itching, scaling, maceration, fissures between toes, fingers
ο Spreading to soles of foot or palms of hand
ο Occasionally hyperkeratotic lesions, sometimes only scaling of palm
Tinea corporis:
ο Can affect groin, body and head
ο Round scaly areas with elevated papular border, initially erythematous, later often hyperpigmented
ο Occasionally pustules
ο Lesions may merge producing larger areas.
Tinea capitis:
ο Round scaly area, erythematous, with papules, inflammation;
occasionally folliculitis
ο If treated late permanent alopecia (due to scars) may develop.
Treatment:
Body and clothes should be washed daily.
Local treatment only effective in hairless areas; otherwise additional
systemic treatment necessary
Tinea pedis, manuum:
ο Gentian violet solution 0.5% bid-tid
ο Whitfield’s ointment bid-tid
ο Clotrimazole cream 1% bid-tid
ο Duration of treatment: at least 3 weeks
Tinea with hyperkeratosis on hand or feet, onychomycosis, tinea
corporis:
ο Griseofulvin:
> Adults: 500-750 mg od
> Duration of treatment: 4 weeks
ο Ketokonazole:
> Adults: 200 mg od
> Duration of treatment: 2-3 weeks
> Avoid in children.
Tinea capitis:
ο Remove hair next to affected scalp areas.
ο Treat with griseofulvin or ketokonazole according to availability.
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Skin Problems
12.5.2 Candidiasis (thrush)
Causative agent:
Mainly candida albicans
Oropharyngeal:
ο White plaques on inflamed mucosa of mouth
Vaginal:
ο White creamy discharge, inflamed mucosa, pruritus
Cutaneous:
ο Red rash, wet, with papules or pustules
ο On perineum (e.g. nappy rash in babies) or in skin folds
ο White soggy-looking skin in interdigital space
Severe widespread infections (also systemic) in immunocompromised
patients, e.g. patients infected with HIV
Treatment:
Skin should be cleaned on a daily base.
Oropharyngeal thrush:
ο Nystatin suspension or gel qid
ο Duration of treatment: 1 week
Vaginal thrush:
ο Clotrimazole 500 mg vaginal tablet single dose or 200 mg on 3
consecutive nights
ο Treat sexual partner, advise condoms during treatment.
Cutaneous thrush:
ο Clotrimazole cream 1% bid-tid
ο Duration of treatment: up to 1 week after the disappearing of lesions
(at least 3 weeks)
Widespread lesions esp. in immunocompromised patients e.g.
patients with HIV:
ο Ketokonazole 3-5 mg/kg od
ο Duration of treatment: 2-4 weeks
Synthetics should be avoided; in nappy rash: expose bottom of child
to air as much as possible.
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Skin Problems
12.5.3. Pityriasis (tinea) versicolor
•
Very common in the tropics
Causative agent:
Pityrosporon ovale (malassezia furfur)
Hypo- or hyperpigmented macules, irregularly shaped, with scales
On trunk, esp. back, upper arms, neck
Pityriasis alba:
ο Eczema, mainly in children (face), but also adults
ο Different areas of the body affected, esp. arms and legs
ο With white, well demarcated areas
ο Occasionally slight pruritus
ο Self-limiting; no treatment necessary
Vitiligo: persistent hypopigmented macules
Leprosy: single or few macules
Treatment:
Clotrimazole 1% cream bid-tid
Whitfield’s ointment bid-tid
Duration of treatment: at least 3 weeks
12.6. Infestation of the Skin
12.6.1. Scabies (seven year itch)
•
•
World-wide infection
In areas without proper hygiene, with poverty and/or overcrowding
Causative agent:
Sarcoptes scabiei
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Skin Problems
Transmission:
Person-to-person (female mite), through clothes and bedding
♻
Life cycle:
Female mite lays eggs in a burrow in the skin.
Larvae hatch, mould, undergo several stages and mature into adults.
After fertilization on the surface females start burrows again.
Transmission can occur at any time after infection with mites.
Incubation period: 6-8 weeks until appearance of rash
Initially small itchy papules (burrows with eggs and secretion of mites)
After sensitization of skin generalized rash with vesicles and nodules,
esp. between fingers and toes, wrists, genitals, buttocks, arms and
legs
Itch severe at night
Scratching often leads to secondary infection.
Treatment:
All members of the household should be treated at the same time
(even if asymptomatic).
Advice regarding cleanliness (daily bath) is very important.
All clothes and bedding should be washed daily and dried in the sun.
Benzyl benzoate 25% emulsion:
ο Adults, children > 10 years:
> After bath apply emulsion to whole body from neck downward
(including area behind the ears).
ο Younger children:
> Dilute to half strength (12.5%).
> Include head in treatment.
ο Leave overnight and wash off in the morning.
ο Treat for 3 consecutive days.
ο Treat whole family at the same time.
ο Treatment of large communities and problems with compliance:
repeat treatment after 10 days.
In superinfected scabies:
ο Cloxacillin:
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Skin Problems
>
Adults: 500-1000 mg qid
or
ο Cefuroxime:
Topical treatment:
ο Gentian violet solution 0.5% and povidone iodine ointment/solution for pustules
Often itch persists for several weeks (i.e. an allergic reaction to dead
mites, not a treatment failure); if recurrence of papular itchy lesions:
recurrence of illness likely
Severe pruritus:
ο Diphenhydramine:
> Children: 1-2 mg tid prn
> Adults: 50 mg up to tid prn
Ivermectin:
ο Perhaps treatment of choice in the future (advantage: tablets only,
better compliance, less treatment failure), but too expensive at
present
12.6.2. Pediculosis (louse infestation)
•
World-wide; in areas with poor hygiene
Causative agents:
Pediculus humanus (body louse)
Pediculus capitis (head louse)
Phthirus pubis (crab louse)
♻
Life cycle:
Female louse attaches eggs firmly to body hair (close to the skin) or
folds of clothing (P. humanus).
Nymphs hatch, develop into adult lice in about 3 weeks; both suck
blood several times during the day.
Transmission:
Close contact, clothes, bedding
183
Skin Problems
Papular rash with itching
Intense scratching leading to secondary infection
P. humanus can transmit louse-borne typhus or relapsing fever.
Always remember: impetigo of the scalp or neck can be caused by infestation
with head lice.
Treatment:
Easiest solution is to shave head or affected areas; otherwise:
Hair should be washed daily and combed with a fine comb.
Benzyl benzoate 25% emulsion (diluted 1:3 with clean water):
ο Apply to affected areas (avoid contact with eyes).
ο Leave overnight, wash hair in the morning.
ο Apply on 3 consecutive days.
Patient to check for nits: they may need to be removed with comb or
fingers.
Give antibiotics in severe infection.
Clothes and bedding should be washed and boiled and left to dry in
the sun.
12.7. Burns
•
Mainly small children affected who play close to open fires and cooking
pots
st
1 degree burns: redness
nd
2 degree: blistering of skin
rd
3 degree: deep burn: black charred skin, diminished sensitivity
Secondary infection possible
Pain and fluid loss can lead to shock.
Assessment:
Time of accident
What happened?
Depth of burn
184
Skin Problems
Extent of burned areas (rough estimate):
ο Children:
> Entire head: 18%
> Arm: 9%
> Leg: 14%
> Front of chest and abdomen: 15%
> Back of chest and abdomen: 15%
> Buttocks: 3% each
ο Adults:
> Head: 9%
> Front of trunk: 18%
> Back of trunk: 18%
> Arm: 9%
> Hands 1%
> Leg: 18%
Treatment:
Burned area must be dipped in cool water or cooled down with cold
compresses immediately to prevent major damage!
st
1 degree burn:
ο Painkillers e.g. paracetamol PO:
> Adults: 500-1000 mg up to qid
ο For severe pain: tramadol PO, IV, IO, IM if available:
> Children 1-11 years: 1-2 mg/kg up to tid prn
> Children ≥ 12 years, adults: 2 mg/kg tid prn
nd
2 degree burn:
ο Avoid bursting the blisters.
ο Open blisters: gently clean burned area.
ο Silver sulphadiazine (flamazine) to affected areas to prevent
infection:
> Caution: avoid silver sulphadiazine in pregnancy (esp. in the
last trimester), in breast-feeding women and in neonates (risk
of neonatal haemolysis and methaemoglobinaemia; also
question of increased risk of kernikterus). Use in pregnancy
only if benefits are greater than risk to foetus.
185
Skin Problems
>
ο
Avoid using silver sulphadiazine for large areas (increased risk of
side effects of sulphonamides e.g. leucopenia or rash).
Apply clean dressing to burns. Dress each finger or toe
separately.
Alternatively:
ο
ο
ο
ο
Clean burns.
Dressing with sofratull and povidone iodine solution/ointment
Infected burns: broad-spectrum antibiotics e.g. amoxicillin
Painkillers e.g.:
> Children:
− Paracetamol 30 mg/kg PO in 3-4 divided doses or
− Tramadol 1-2 mg/kg PO, IV, IO, IM tid if available or
− Metamizole ½ drop/kg (= 10 mg/kg) PO in 3 divided
doses
> Adults:
− Paracetamol 500-1000 mg PO qid or
− Tramadol 2 mg/kg PO, IV, IO, IM up to tid or
− Metamizole 18-36 drops PO up to qid
ο Rehydration:
> Increase fluid intake:
− Normal fluid requirement (see Moderate dehydration plan
B, p.91)
− Add 20 mL/kg for every 10% of body surface or part of it
− Give ORS (oral rehydration solution), in severe burns IVinfusion e.g. with Ringer’s Lactate solution.
ο Give tetanus prophylaxis.
Refer to hospital:
ο Severe burns (> 25% body surface)
rd
ο 3 degree burns
ο Burns to face and eyelids
ο Patients with contractures
Note:
For change of dressing it might be necessary to give ketamine.
186
Skin Problems
12.8. Wounds
General guidelines:
• Wounds older than 6 hours should not be sutured; in remote areas this
rule can be stretched to up to 24 hours if the patient can be observed
afterwards for any sign of infection.
• Infected wound or incised abscesses should never be sutured.
• Wounds due to bites of animals or humans should not be sutured.
• “Open fracture” means that there is a break in the skin overlying the
fracture.
• Always give antitetanus prophylaxis if not fully immunized.
Treatment:
Clean wound and surrounding area (e.g. with povidone iodine solution
or Ringer’s Lactate solution).
Anaesthetize with lidocaine 1% or 2%.
Explore wound to exclude foreign bodies, underlying fracture,
involvement of other structures e.g. tendons, major blood vessels etc.
Clean wound thoroughly.
Use interrupted sutures (non-resorbable sutures e.g. silk for skin,
resorbable sutures e.g. chromic catgut for subcutaneous tissues).
Use finer suture material e.g. 3/0 for face, thicker material e.g. 2/0 for
scalp or limbs (the higher the numbers the finer is the suture material).
Removal of sutures: face: after 5 days; other wounds: after 7 days;
wounds overlying joints: after 10 days
Note:
When treating wounds do not forget to give tetanus prophylaxis and, with
dirty or infected wounds, antibiotics e.g. cefuroxime or erythromycin.
187
Ophthalmological Problems
13.
OPHTHALMOLOGICAL PROBLEMS
13.1. Cataract
•
•
•
Most common cause of blindness worldwide
In tropical regions: occurring about 10 years earlier than in Western
countries
Risk factors: possibly associated with sunlight, malnutrition, diabetes
mellitus, hypertension
White opacity in pupil
Decreasing visual acuity
Increased glare
Treatment:
Surgery (only if both eyes affected; eye camps in some of our projects
e.g. in the Philippines)
Normally glasses used for aphakic correction
In some hospitals: intraocular lens implantat
Note:
An operation is important to avoid permanent blindness which leads to loss of
income and additional burden to the family (the blind needing to be looked
after permanently by a member of the family).
13.2. Conjunctivitis
Causative agents:
Bacteria, viruses, fungi; often highly contagious
Also: allergic in origin (often associated with hay fever)
Visual acuity usually not affected
188
Bacterial/fungal conjunctivitis:
ο Red eye, irritation
ο Purulent discharge
ο Occasionally with chemosis
ο Ophthalmia neonatorum: see chapter STD, p.143
Viral infection:
ο Red eye
ο Watery discharge
ο Occasionally: keratitis (severe pain, photophobia) or secondary
bacterial infection
Allergic conjunctivitis:
ο Red eye
ο Severe pruritus
ο Watery discharge
ο Eyelid oedema
ο Often associated with other allergic diseases e.g. eczema or
asthma
Treatment:
Bacterial conjunctivitis:
ο Chloramphenicol 0.5% eye drops tid for 5-7 days
ο Tetracycline 1% ointment (for very watery eyes) tid for 5-7 days
ο If severe illness: treat for up to 14 days (esp. in neonates).
Viral conjunctivitis:
ο Cold compresses
ο Antibiotic eye drops or ointment for secondary infection
Allergic conjunctivitis:
ο Cold compresses
ο Severe illness: antihistamines PO e.g. diphenhydramine:
> Children: 2 mg/kg tid prn
Eyes should be cleaned regularly with normal saline.
Do not pad an infected eye.
189
☂
Prevention:
Advice to wash towel or cloth thoroughly and dry in the sun after
cleaning the infected eye
Advice not to share towels or cloths
Hands should be cleaned with soap and water after applying eye
drops or touching the infected eye.
Advice to avoid touching a non-infected eye after touching the infected
eye
13.3. Pterygium
•
•
Very common in the tropics (possibly due to high exposure to ultraviolet
light)
More common in males than in females
Fibrovascular mass on the surface of conjunctiva and cornea
Growing across the cornea from temporal or nasal side
Flat or raised and injected
Can grow rapidly.
Possible: itching, irritation, visual disturbance
Pinguecula:
ο Small asymptomatic nodules (often yellowish) on bulbar surface of
conjunctiva
ο Not extending to cornea
Treatment:
Normal saline drops for irritation or itching
Operation only with visual problems; high recurrence rate
190
13.4. Trachoma
•
•
•
•
•
Most common eye disease in the world (500 million people infected),
major cause of blindness, second only to cataract
Endemic in dry and hot areas of Africa, India and South-East Asia
Disease of poverty, associated with poor hygiene, lack of water and
overcrowding
Risk factors (five D’s): dry, dusty, dirty, density (overcrowding of homes),
(eye-) discharge
Mainly in children between 1 to 6 years; also affected: contacts e.g.
mothers and older siblings
Causative agent:
Chlamydia trachomatis type A-C
Transmission:
Flies, faeces, fingers, contaminated clothes (smear infection)
Problem: recurrent episodes of infection and bacterial superinfection
leading to scarring of conjunctiva and cornea with subsequent
blindness
Usually both eyes affected
Stage I:
ο Trachomatous inflammation - follicular (TF):
> 5 or more follicles (white, grey, yellow) in the upper tarsal
conjunctiva
Stage II:
ο Trachomatous inflammation - intense (TI):
> Intense inflammation with red, thickened conjunctiva of the
upper lid
> Follicles
Stage III:
ο Trachomatous scarring (TS):
> Scarring of the tarsal conjunctiva (white lines or bands in the
upper tarsal conjunctiva)
> Increased risk of entropium with resulting trichiasis
191
✎
Stage IV:
ο Trachomatous trichiasis (TT):
> At least 1 eyelash rubbing the cornea
> Ulceration and chronic inflammation of cornea
Stage V:
ο Corneal opacity (CO):
> Vascularization of cornea (pannus)
> Scarring of cornea
> Loss of vision
Diagnosis:
Early diagnosis crucial for prognosis
Important: Examination of conjunctiva and cornea for inflammation
and discharge:
ο Evert upper eyelid and examine the tarsal conjunctiva for
inflammation, follicles or scarring (ask the patient to look down
and pull the eyelashes up while rotating the upper eyelid against a
matchstick or similar object).
ο Check for corneal opacities.
Treatment:
Only early treatment can prevent blindness, only early stages can be cured
completely.
192
Stage I/II:
ο Facial cleanliness:
> Cleaning of eyes and face several times during the day with
clean water
ο Systemic antibiotic treatment:
> Azithromycin:
− Child > 6 months: 30 mg/kg single dose
− Adults: 1 g single dose
> Treat whole family.
> If azithromycin not available give:
ο Topical treatment:
> Tetracycline eye 1% ointment to be applied bid for 6 weeks to
both eyes
☂
Stage III:
ο Surgical intervention as early as possible to avoid persistent
corneal damage
WHO strategy:
ο SAFE: surgery (for trichiasis), antibiotics, facial cleanliness,
environmental improvement (improved access to clean water)
ο Goal: eradication of blinding trachoma by 2020
Prevention
Education regarding cleanliness and hygiene is very important to
prevent transmission and reinfection (e.g. advice regarding regular
daily face and hand washing with clean water).
Education regarding use of latrines and burning of rubbish etc.
193
ENT Problems
14.
ENT PROBLEMS
14.1. Otitis Externa
•
Diffuse inflammation of the skin in the external ear canal
Causative agents:
Bacterial infection (e.g. staphylococci or pseudomonas)
Fungal infection (e.g. candida albicans)
Trauma of the ear canal
Irritation
Discharge (”runny ear”)
Pain on moving the pinna or compression of the tragus
Deafness
Tympanic membrane intact
Treatment:
Aural toilet:
ο Flush external ear canal gently with normal saline.
ο Mop ear dry from the outside.
ο Wait for 10 minutes before applying ear drops.
Chloramphenicol 0.5% ear drops: 2 drops tid or
Gentamycin 0.5% ear drops: 2 drops tid
Duration of treatment: 5-7 days
Tragus massage after application of ear drops
14.2. Otitis Media
•
•
•
•
194
Common disease in childhood
Often chronic in older children, esp. with impaired resistance e.g. through
malnutrition or measles (chronic suppurative otitis media)
If untreated risk of ossicular destruction and hearing loss
Often combined with common cold, tonsillitis, sinusitis
ENT Problems
Causative agents:
Bacteria e.g. pneumococci, streptococci, haemophilus influenzae
Viruses
Acute:
ο Pain
ο Deafness
ο Pyrexia
ο Inspection: dull ear drum, bulging; purple colour; sometimes
perforation of ear drum with discharge
Chronic:
ο Perforated ear drum
ο Smelly discharge (”runny ear”)
ο Complications: cholesteatoma, mastoiditis, labyrinthitis, meningitis
etc.
Note:
All children with fever, diarrhoea or vomiting should have their ears checked.
Treatment:
Acute otitis media:
ο Antibiotic treatment e.g.:
> Amoxicillin:
− Children: high dose of 80 mg/kg in 3 divided doses
− Adults: 500 mg tid
− Duration of treatment: children < 2 years: 10 days;
children > 2 years, adults: 5-7 days
> If allergic to penicillin give erythromycin:
− Children: 50 mg/kg in 3 divided doses
− Adults: 500 mg tid-qid
ο Paracetamol for pain and pyrexia
Chronic suppurative otitis media:
ο Aural toilet 3 to 4 times/day:
> Flush external ear canal gently with normal saline.
195
ENT Problems
ο
ο
ο
> Mop ear dry from the outside.
> Wait for 10 minutes before applying ear drops.
> Important: education of patient how to mop ear canal
Chloramphenicol ear drops tid or gentamicin ear drops: 3 drops
tid-qid to ear canal
> Tragus massage after application
> Duration of treatment: 2 weeks minimum
With first manifestation of aural secretion: trial of amoxicillin or
cotrimoxazole for 2 weeks
Refer to hospital in case of complications e.g. mastoiditis
(persistent pain, discharge, pyrexia, swelling and tenderness
behind the ear).
14.3. Cerumen
•
•
•
Try to avoid manipulation e.g. syringing of the ear – there is always a risk
of causing an infection (esp. if the patient has a perforated ear drum).
Better: use oil (e.g. coconut oil) to soften the wax: apply nightly for at least
one week instilling the oil when lying on the side; the wax will be removed
by the hair in the ear canal.
Syringing with warm water is rarely needed.
14.4. Rhinitis/Sinusitis
•
•
•
•
•
Use saline nose drops (0.9% NaCl) to liquefy nasal secretions; for infants
instil nose drops 10 minutes before feeding.
Children > 4 years, adults with yellow discharge, fever and headache:
consider sinusitis; treat with antibiotics such as amoxicillin or
cotrimoxazole and paracetamol for fever and pain.
Advice regarding salt water douches (sniffing a little salt water into each
nostril)
With pain over sinuses: always check for dental problems, e.g. abscess.
Unilateral purulent discharge: check for foreign body in the nostril.
196
ENT Problems
14.5. Acute Tonsillitis
•
Most frequent under the age of 9
Causative agents:
Mainly streptococci
Viruses
Spread by droplet infection
Sore throat
Dysphagia
Earache, headache
Pyrexia
Tonsils enlarged, inflamed, occasionally with exudate
Tender cervical lymph glands
Complications:
ο Acute otitis media, peritonsillar abscess (quinsy)
ο Acute nephritis, rheumatic fever
Viral tonsillitis less severe
Treatment:
Paracetamol or aspirin (adults) for pain and pyrexia
Penicillin V:
ο Children: 30-60 mg/kg in 3-4 divided doses
ο Adults: 500 mg qid
Erythromycin (for patients with penicillin-allergy):
ο Children: 50 mg/kg in 3 divided doses
ο Adults: 500 mg tid-qid
Treat for 10 days to avoid complications.
Salt water gargles (1 teaspoon of salt in 1 glass of warm water)
197
Different Other Conditions
15.
DIFFERENT OTHER CONDITIONS
15.1. Endocrinological Problems
15.1.1. Goitre
15.1.1.1. Iodine deficiency
•
•
Most common cause of goitre
Endemic in some areas; contributing factors: malnutrition, staple foods
such as cassava or cabbage or increasing iodine requirement during
puberty, pregnancy and breast feeding
✎
Usually euthyroid
ο First: diffuse enlargement
ο Later: regressive changes with mononodular, then multinodular
goitre with risk of developing autonomous areas and hyperthyroidism
Maternal iodine deficiency during pregnancy (euthyroid or
hypothyroid) leading to endemic cretinism in the infant with:
ο Poor feeding, constipation, hypotonia, prolonged neonatal
jaundice
ο Later: growth failure, deaf-mutism and mental retardation
Diagnosis:
Palpation
Check TSH if hyper- or hypothyroidism is suspected (raised in only
20%).
Treatment:
Iodized salt
Operation only if there is danger of compression of the trachea
☂
198
Prevention:
Regular use of iodized salt e.g. in bread or added after cooking
Advice regarding food: increase consumption of seafood or seaweed
(as most of the iodine is found in the water after cooking: prepare
soup or sauces)
Avoid cassava or water it for one hour before preparing the meal.
15.1.1.2. Hypothyroidism
Causes:
In our projects: mainly side effect of treatment (e.g. with carbimazole
or post-operative)
Autoimmune disease (M. Hashimoto)
Congenital
✎
Bradycardia
Dry, thickened skin
Non-pitting oedema
Diagnosis:
TSH
Treatment:
L-thyroxin 50-100 mcg od
15.1.1.3. Hyperthyroidism
Causes:
Graves’ disease (usually with goitre but sometimes without goitre)
Toxic adenoma
Restlessness, tremor, tachycardia
Weight loss, diarrhoea, weakness
Goitre with thyroid bruit
Exophthalmos (can be unilateral)
199
✎
Diagnosis:
Clinical manifestations
TSH; if low TSH (< 0.3): check T4 prior to treatment with carbimazole.
Ultrasound of goitre (to differentiate between Graves’ disease and
toxic adenoma)
Treatment:
Do not start treatment without hormone tests for confirmation of diagnosis.
200
Therapeutic:
ο Carbimazole:
> Start with 10 mg (up to 30 mg) od (according to initial T4).
> Check T4 after 4 weeks, then after 3 months and adjust
treatment according to result (repeated checks of TSH not
necessary as it takes a long time to adjust).
> Maintenance dose: 2.5-15 mg od
> Side effect: agranulocytosis (1%); occurs suddenly: therefore
check white cell count only in symptomatic patients (sore
throat, fever, other signs of infection); stop treatment
immediately.
Symptomatic (with tremor and tachycardia):
ο Metoprolol:
> Give 50-100 mg od
> Improves tremor and tachycardia and reduces the conversion
of T4 to T3.
> Adjust according to heart rate and blood pressure; if normal:
stop.
Duration of treatment:
ο Graves’ disease:
> Try to stop treatment after 12-18 months.
> In 50% remission after 12-18 months; if symptoms recur
consider referral for operation (subtotal thyroidectomy).
ο Toxic adenoma: treatment life-long; consider referral for operation.
> Clinical hyperthyroidism
> Treatment:
> Subclinical hyperthyroidism
> Avoid iodine
> Observe
> Carbimazole 10 mg od
> Consider: Metoprolol ret.
50 mg od
> Nodules (toxic adenoma)
> Life-long treatment or operation
Ultrasound scan of thyroid gland
+ Arrange
> Diffuse enlargement
(Graves’ disease)
> Stop carbimazole after 12-18 months
> Observe
> After 4 weeks: check T4
> Adjust dose of carbimazole (maintenance dose: 2.5-15 mg od)
> Aim for normal values of T4
T4 raised (> 2 ng/dl)
T4 normal
TSH < 0.3 mU/l
Diagnosis and Therapy of Hyperthyroidism
201
•
•
•
202
Avoid hypothyroid stage – risk of deterioration of ophthalmopathy and
enlargement of goitre.
Patients with goitre should be checked at each consultation regarding
heart rate, blood pressure and weight to avoid problems under therapy.
Patients must be asked to present immediately with signs of infection,
especially with fever or sore throat; if this happens they must be told to
stop treatment with carbimazole.
15.1.2. Diabetes mellitus
•
•
Prevalence dependent on age
Increasing in developing countries due to population growth and urbanization and increasing prevalence of obesity and physical inactivity
2 types of diabetes mellitus:
Type I
Diabetes mellitus
Type II
Diabetes mellitus
Frequency
(% of population
worldwide)
< 10%
> 90%
Cause
Autoimmune disease, loss of
pancreatic beta cells
Insulin secretory defect,
insulin resistance
Age of onset
Mainly affected: children, young
people
> 40 years
Onset
Abrupt
Slow
Constitution
Lean, weight loss
Obese, increasing weight
Ketoacidosis
Common
Rare
Sulfonylureas
Not effective
Effective
Polyuria, polydipsia
Weight loss, lethargy
Dehydration, with visual disturbance and leg cramps
Pruritus, skin infections (bacterial, fungal)
Untreated: coma, death
Complications:
ο Peripheral neuropathy e.g. bilateral lower extremity sensory
neuropathy (burning feet), diabetic foot with painless ulcers
ο Microangiopathy e.g. retinopathy, nephropathy
ο Macroangiopathy: myocardial infarct, stroke
ο Often associated with hypertension
203
✎
Diagnosis:
Random blood sugar: > 200 mg/dl (11.1 mmol/l)
Fasting glucose: > 125 mg/dl (7.0 mmol/l)
Urine dipstick: positive for ketones
Treatment:
Every patient with diabetes mellitus must be referred to a diabetic clinic if at all
possible; regular check-ups are of utmost importance, esp. in patients on
insulin and sulfonylureas.
204
Type II Diabetes mellitus:
ο First line treatment:
> Advice regarding diet, exercise and weight reduction (avoid
food containing sugar; advice to eat several small meals and
to avoid fat)
ο Second line treatment: oral medication in cooperative patients:
> Metformin (for insulin resistance):
− Initially 500 mg od (up to 1000 mg bid)
− Contra-indications: renal impairment, cardiac failure,
respiratory failure, hepatic impairment; has to be stopped
in any severe illness (e.g. tuberculosis, pneumonia or
dehydration), prior to investigations with x-ray contrast
media or 48 h prior to general anaesthetic.
− Side-effects: nausea, vomiting, rarely: lactic acidosis
− Note: Problem with fasting periods during Ramadan
(medication to be taken at night)
− Advantage: no risk of hypoglycaemia
> Glibenclamide (sulfonylurea; stimulation of beta cells):
− Dosage: 1.75 mg (up to 10.5 mg); give 2/3 of medication
in the morning, 1/3 in the evening.
− To be taken before meals
− Side effect: hypoglycaemia, esp. with irregular food intake
− Contraindicated in pregnancy
Type I Diabetes mellitus:
ο Mixed insulin SC:
> Give 2/3 in the morning, 1/3 at night.
> Side-effect: hypoglycaemia, esp. with irregular food intake
Only to be given in rare cases:
> Cooperative patient
> Education of patient and close follow-up e.g. in diabetic clinic
or with local coordinator
> Problems:
− No home glucose testing
− Storage (no refrigerator)
Hypoglycaemia:
ο Side-effect in treatment with sulfonylureas (prolonged hypoglycaemia) and insulin
ο Clinical manifestations:
> Hunger, nausea, restlessness, tremor
> Sweating, tachycardia
> Seizures, coma
ο Treatment:
> Mild hypoglycaemia, conscious patient:
− Give sugary drink e.g. coca-cola.
− Then give long-acting carbohydrates e.g. biscuits, bread.
− Recheck blood sugar prior to discharge of patient.
> Severe hypoglycaemia, semi- or unconscious patient:
− 40% glucose IV: 40-100 mL stat (with frequent blood
glucose checks), then
− 5% glucose IV (up to blood sugar of 200 mg/dl)
− Refer to hospital.
Follow up:
ο History: ?problems ?hypoglycaemia
ο BM-stix or blood glucose
ο Blood pressure check
ο Urine dipstick ?albumin (rule out UTI)
ο Serum creatinine with possible nephropathy
ο Check feet (pulses, sores, nails), advice to wear slippers or shoes
for protection.
ο Education and referral to diabetes clinic
ο
Gestational diabetes:
•
•
Glucose intolerance, first onset during pregnancy
Increased risk of developing type II diabetes mellitus after delivery
205
Treatment (only by specialist):
Diet advice (e.g. avoidance of sugar, several small meals)
Insulin SC
nd
rd
Metformin PO (only studies with patients in 2 and 3 trimester; can
be given in the first trimester if benefit outweighs the risk; not known to
be teratogenic in animals)
15.2. Epilepsy
•
•
Seizure: due to paroxysmal discharge of cerebral neurones
Epilepsy: should only be diagnosed after 2 seizures
Causes:
Hereditary: low seizure threshold
Brain disorders e.g. after perinatal hypoxaemia
Acute infections or trauma to the central nervous system e.g.
encephalitis, meningitis, haemorrhage, abscess, cysticercosis,
cerebral malaria
Drugs, alcohol or withdrawal of drugs; poisoning
Metabolic disorders e.g. hypoglycaemia, uraemia, dehydration etc.
Intracranial tumors
Pyrexia: febrile convulsions in children
206
Classification:
ο Generalized seizures (grand mal seizures; neuronal discharge
involving both hemispheres, generalized symptoms):
> Primary or secondarily generalized (following partial seizure)
> Mainly idiopathic, but can be hereditary or due to brain
disorders
> Preceding aura in secondarily generalized seizures
> Sudden loss of consciousness with tonic/clonic movements of
limbs, lasting for several minutes, then post-ictal confusion or
drowsiness
> Often with tongue bite and/or incontinence of urine or faeces
>
ο
ο
Absence seizures (petit mal):
− Childhood disorder, may develop into grand mal fits in
adult life
− Sudden onset, child stops all activity, looks vacant for a
few seconds, then resumes previous activity.
Partial seizures (neuronal discharge involving part of the brain;
focal symptoms):
> Simple partial seizure:
− Consciousness not impaired
− Motor, sensory or autonomic disturbance depending on
site of origin in brain
> Complex partial seizure:
− With aura
− Consciousness impaired
− Verbal or motor automatisms depending on area of brain
involved
Febrile seizures (convulsions):
− Age: 6 months to 5 years
− Tonic-clonic seizure, focal seizure
− Often less than 15 minutes
− No neurological deficit
✎
Vasovagal syncope: occasionally accompanied by rhythmic jerks; no
post-ictal drowsiness
Chilling: tremor, no loss of consciousness, no post-ictal phase
Underlying causes e.g. meningitis, encephalitis, malaria, tuberculosis,
parasitic disease e.g. schistosomiasis, cysticercosis etc.
Diagnosis:
Detailed history including family history and detailed description of fits
Temperature
Blood sugar
In rare cases: EEG, CT-scan
207
Treatment:
Emergency treatment:
ο Keep calm – usually a seizure is not a life threatening event and
resolves spontaneously.
ο Prevent patient from injuring himself.
ο Secure airway, if possible recovery position.
ο Give oxygen if available.
ο If seizure longer than 5 minutes:
> Diazepam (0.5-0.7 mg/kg):
− Children < 15 kg: 5 mg PR
− Children > 15 kg, adults: 10 mg PR (use parenteral solution in syringe)
− Status epilepticus: diazepam IV (slowly over 3 minutes)
> With fever:
− Sponging with tepid water
ο Treat underlying causes (e.g. meningitis, malaria).
Long-term treatment:
ο General aspects:
1
> To avoid side effects: start with /3 of dose and increase in
intervals from 3 days up to 3 weeks.
> Always give lowest dose controlling the epilepsy, preferably
monotherapy.
> Consider side effects e.g. hepatotoxicity.
> Pregnant women: problems with teratogenicity, esp. in the
first trimester; important: referral to specialist
> Avoid quinolones if possible (e.g. ciprofloxacin; side effect:
convulsions)
ο Generalized seizures:
> First line treatment:
− Sodium valproate 20 mg/kg in 2 divided doses; start with
5-10 mg/kg
> Second line treatment:
− Phenobarbital up to 5 mg/kg od
> Secondarily generalized seizures:
− If grand mal while asleep: Carbamazepine 20 mg/kg in 2
divided doses
208
ο
ο
ο
ο
Partial seizures:
> First line treatment:
− Carbamazepine 20 mg/kg/day in 2 divided doses (up to
1200 mg/day)
> Second line treatment (for children > 6 years, adults):
− Sodium valproate 20 mg/kg in 2 divided doses; start with
5-10 mg/kg or
− Phenytoin 5 mg/kg in 2 divided doses
If not controlled add:
− Phenobarbital up to 5 mg/kg od
Febrile seizures (convulsions):
> Consider prophylactic medication only with more than 4
seizures.
> Phenobarbital up to 5 mg/kg od or
> Sodium valproate 20-30 mg/kg in 2 divided doses
Side effects:
> Sodium valproate:
− Hair loss
st
− Teratogenic: avoid in the 1 trimester: increased risk of
neural tube defects
− Rarely hepatic failure
> Carbamazepine:
− Allergic reactions, hair loss
st
− Teratogenic: avoid in the 1 trimester: increased risk of
neural tube defects; adequate folate supplements
advised, therefore start folic acid prior to pregnancy.
− Interactions with theophylline, digoxin, erythromycin,
furosemide, phenobarbital
− Storage: tablets must be stored in a dry place.
> Phenobarbital:
− Sedation, esp. in adults
− Behavioural disturbances, hyperactivity (children)
− Risk of rebound seizures on withdrawal
− Pregnancy: risk of congenital malformations
− Interactions with carbamazepine (reduced plasma concentration), phenytoin, sodium valproate
− Hepatitis, cholestasis
− Allergy
209
>
☂
Phenytoin:
− Small increase in dosage may produce large rise in
plasma concentration
− Acne, hirsutism, gingival hyperplasia
− Megaloblastic anaemia (treatment with folic acid)
− Rarely: hepatotoxicity
− Congenital malformations
− Interactions with phenobarbital, digoxin, furosemide,
cimetidine, theophylline, vitamin D (increased requirement)
Withdrawal of medication:
ο May be attempted after 2-3 years without seizures and normal
EEG.
ο Avoid abrupt withdrawal: risk of rebound seizures.
ο Important: gradual reduction of medication over several weeks (up
to months)
ο In patients with several drugs: gradual withdrawal of one drug at a
time
Prevention:
Avoid alcohol, lack of sleep
Drug treatment only in cooperative patients (convulsions may be
caused by sudden withdrawal of anticonvulsants) and frequent
seizures
Febrile convulsions: paracetamol and tepid sponging with increasing
temperature
•
•
210
Taking a detailed history is of utmost importance.
Think of epileptic fit in a patient with sudden loss of consciousness
lasting seconds to minutes, incontinence and subsequent disorienttation or coma.
Diagnosis:
Cerebral seizures
Automatisms:
> Verbal e.g. moaning
stereotyped speech
> Motor e.g. smacking,
fumbling
Aura:
e.g. abdominal sensation,
tingling, visual changes
Complex:
not Consciousness
impaired
> Jacksonian:
jerky rhythmic movements
> Sensory e.g. numbness, pain,
auditory, olfactory sensations
etc.
> Autonomic e.g. tachycardia,
epigastric sensations, miosis
etc.
Simple:
Consciousness
impaired
Partial seizures
> Temperature
> Blood sugar
> Microscopy e.g. faeces (schistosomiasis)
> In rare cases: CT, EEG
Febrile seizures (convulsions)
> Tonic-clonic or focal
> Less than 15 minutes
> Fever
> No neurological deficits
> Normal EEG
> Family history of febrile
convulsions
Classification of seizures
Often aura
Following
partial seizure
No aura
211
> Tonic-clonic (grand
mal) with post-ictal
state
> Absence seizures
(petit mal)
> Also: atonic,
myoclonic
Secondarily
generalized
Primarily
generalized
Generalized seizures
> Gradual increase until control of
seizures
(intervals from 3 days up to 3 weeks)
> Antipyretic treatment with
temperature > 38.5°
esp. in the first 24 hours
> Consider phenobarbital up to
5 mg/kg od or
> Consider sodium valproate
20-30 mg/kg in 2 divided
doses
212
> Medication must be
taken regularly
> Preferably monotherapy
> Consider side-effects e.g.
hepatotoxicity
> If possible avoid
treatment with quinolones
e.g. ciprofloxacin
(Side effect: convulsions)
Starting therapy:
Prophylaxis (if more than 4 convulsions):
Generalized Seizures
see opposite page
Partial Seizures
see opposite page
Withdrawal of medication:
> Free of seizures for 2-3 years
> Normal EEG
> Gradual withdrawal over several
weeks depending on medication
General information
Seizures:
Febrile
Seizures
(Convulsions):
Long-term Therapy of Seizures
> Phenobarbital up to 5 mg/kg od
carbamazepine 20 mg/kg in 2 divided doses
if grand mal while asleep:
Note:
Secondarily generalized
seizures:
> Phenobarbital up to 5 mg/kg od
* if still not controlled
add:
> Phenytoin 5 mg/kg in 2 divided
doses
Second line treatment:
Children > 6 yrs:
> Sodium valproate 20 mg/kg
in 2 divided doses or
in 2 divided doses*
Second line treatment:
in 2 divided doses*
First line treatment:
> Sodium valproate 20 mg/kg
First line treatment:
Generalized Seizures
> Carbamazepine 20 mg/kg
Partial Seizures
213
15.3. Hypertension
•
•
•
Increasing problem in developing countries due to improving living
standards
Risk factor for cardiac disease, stroke, renal failure and arteriosclerosis
In pregnant patients: increased risk of abruption of placenta, eclampsia
and premature labour
Borderline hypertension:
Drug treatment not indicated.
Advise life style changes e.g. smoking cessation, weight reduction,
reduction of alcohol intake, exercise, low salt diet, increased fruit and
vegetable intake.
Diagnosis of hypertension:
At least 3 consecutive readings with blood pressure of 160/100 mmHg
and higher over a period of several days
If hypertension not responding to treatment: exclude secondary
hypertension:
ο Urine dipstick
ο Ultrasound scan of kidneys
ο TSH
Treatment:
In most cases medication must be taken life-long
Medication necessary if non-drug treatment fails
Drug treatment dependent on possible concomitant diseases or race
(ACE-inhibitors less effective in black patients):
ο Hydrochlorothiazide:
> 12.5-25 mg od
> First line treatment for most patients
> Use preferably in black patients.
> Avoid in patients with renal failure (creatinine > 2.0), diabetes
mellitus, gout, and in pregnant patients.
> If necessary can be combined with ß-blocker or ACE-inhibitor.
214
ο
ο
ο
ο
ß-Blocker:
> First line treatment in patients with heart failure or a history of
myocardial infarction
> Bisoprolol 5-10 mg od
> Metoprolol 25-100 mg bid or Metoprolol retard 50-200 mg od
> Avoid in patients with bradycardia, bronchial asthma, COPD,
diabetes mellitus (deterioration of problems).
Methyldopa:
> Indication: hypertension in Pregnancy; see p.165
Calcium-channel-blockers:
> Can be combined with hydrochlorothiazide, especially in black
patients if monotherapy is not working.
> Nifedipine retard: 20 mg od
> Amlodipine: 5-10 mg od
ACE-inhibitors:
> First line treatment in patients with heart failure or a history of
> Enalapril: 10-20 mg od
> Ramipril: 2.5-5 mg od
Avoid treatment with ACE-inhibitors in women of child-bearing age (risk of
malformations).
Hypertensive crisis:
•
•
Severe hypertension e.g. with diastolic BP > 140 mmHg
Can be associated with headache, convulsions, sudden onset of heart
failure and renal failure.
Treatment:
Avoid aggressive treatment e.g. sublingual nifedipine (risk of hypotension,
stroke or myocardial and renal ischaemia).
Advice rest.
Give treatment as above.
215
If complications:
ο Treat as required e.g. GTN-spray SL 1 puff stat., furosemide IV
40 mg stat.
ο Refer to hospital.
To ensure compliance of patients use once daily medication when at all
possible.
•
•
•
•
During consultation it is important to decide whether the raised blood
pressure is genuine or reactive e.g. induced by the visit to the doctor.
At least 3 blood pressure readings on different days are necessary to
make the diagnosis of hypertension.
If hypertension is not responding to treatment exclude secondary
hypertension (hyperthyroidism, renal hypertension). In the tropics 20-30%
of hypertensive problems are due to renal disease.
Patient compliance and continuity of treatment are of utmost importance.
It is useless to treat patients for 3 weeks only.
15.4. Coronary Heart Disease
•
•
•
•
Main cause of death in developed countries
Men affected at an earlier age than women (protective effect of
oestrogen)
Getting more common in developing countries due to increasing
urbanization
2 types:
o Acute coronary syndrome
o Stable coronary heart disease
Risk factors:
Smoking
Diabetes mellitus (high risk group)
Hypertension
Family history: myocardial infarct, stroke
216
Hypercholesterolaemia
Acute coronary syndrome:
ο Acute myocardial infarction:
> Chest pain for longer than 30 minutes, intense, often with fear
of dying, not relieved by nitrates or rest
> Dyspnoea, tachypnoea,
> Pallor, sweating, distress
> Nausea, vomiting
> Complications: arrhythmias, congestive cardiac failure, cardiogenic shock
Stable coronary artery disease:
ο Angina:
> Precipitated by exertion, stress etc.
> Recurrent crushing chest pain, radiating to neck, jaw or arms
> Dyspnoea
> Relieved by rest or nitrates
✎
Cardiovascular disease: perimyocarditis, arrhythmias (?palpitations),
heart valve disease (aortic stenosis), aortic dissection
Pulmonary disease: pulmonary embolism, pleuritis, pneumothorax
Musculoskeletal disease: rib fracture, muscular strain, thoracic nerve
compression
Gastrointestinal disease: oesophagitis, gastric or duodenal ulcer,
pancreatitis, biliary colic
Other diseases: thoracic varicella zoster, rib tumor
Diagnosis:
History (?risk factor, predisposing illnesses, precipitating factors,
duration, family history)
ECG
Cardiac enzymes e.g. troponin (not available in the projects)
217
Note:
ECGs are rarely relevant in patients with stable angina; with suspected
myocardial infarction send patient to hospital straight away.
Treatment:
Acute coronary syndrome:
ο Try to relax patient.
ο Analgesics as available
> Morphine not available in our projects; therefore give
> Tramadol hydrochloride 2 mg/kg IV
ο Oxygen via nasal prongs
ο Glycerol trinitrate 0.5 mg SL (caps) or 1-2 puffs of spray
ο Acetylsalicylic acid 600 mg PO stat, then continue at 150 mg od
ο ß-blocker e.g. metoprolol 100-200 mg od (contraindicated in
patients with bronchial asthma, COPD, bradycardia, heart failure,
hypotension)
ο Treat complications e.g. heart failure (furosemide 40 mg IV stat).
ο Refer to hospital for observation and further treatment.
Stable coronary heart disease:
ο Acetylsalicylic acid 100 mg od
ο Angina:
> Glyceryl trinitrate SL prn
> Metoprolol 100-200 mg od (consider contraindications!)
ο Advice to stop smoking
ο Treat underlying diseases e.g. hypertension, diabetes mellitus.
•
•
218
Pain in the chest is a common complaint, but in most cases not connected
to the heart (e.g. short stabbing pain, pain relieved by moving, pain in
different locations of the chest).
Taking a proper history, examining the patient properly and making a
diagnosis is of utmost importance in the treatment of chest pain.
15.5. Stroke (Cerebro-Vascular Accident)
•
•
•
•
Sudden onset of focal neurological deficit
Mainly due to cerebral infarction (80%), less due to intracranial
haemorrhages (20%)
TIA (transient ischaemic attack): loss of cerebral function for less than 24
hours
PRIND (prolonged neurological deficit, minor stroke): symptoms longer
than 24 hours, but less than 7 days
Risk factors:
Hypertension
Coronary artery disease, atrial fibrillation
Diabetes mellitus
Smoking
Clinically no difference between ischaemic and haemorrhagic stroke
Contralateral hemiparesis, sensory loss
Visual disturbance (diplopia, amaurosis fugax)
Cranial nerve palsy (e.g. facial nerve palsy)
Aphasia, dysarthria
Confusion, loss of consciousness, coma
Epileptic fits
Irregular pulse with atrial fibrillation
Carotid bruit with stenosis of carotid arteries
Hypertensive crisis
Migraine with aura
Hypoglycaemia
Cerebral tumor, abscess, meningitis
Cerebral schistosomiasis
Subdural haematoma after trauma
219
Treatment:
Ensure vital functions (e.g. pulse, breathing, blood pressure,
temperature).
If possible give oxygen via nasal prongs.
Check for hypoglycaemia and treat if necessary.
Lower high blood pressure slowly:
ο First 3 days: tolerate BP up to 220/110 mmHg.
ο With very high BP (diastolic: 240, systolic 130 mmHg): lower by
max. 20% of initial BP.
o
Lower raised temperature (> 37.5 ) with paracetamol and sponging
with lukewarm water.
Start IVI in patients with swallowing difficulties and refer to hospital.
Treat underlying diseases (e.g. diabetes mellitus).
Start rehabilitation program as soon as possible.
Note:
In our projects there is only basic treatment possible; standardized
investigations (e.g. CT-scan of brain) or treatment in stroke unit are not
possible due to lack of availability and funds.
220
Immunizations
16.
IMMUNIZATIONS
In developing countries it is of utmost importance to check the immunization
status and complete immunizations if necessary because:
• normal childhood illnesses can be life threatening due to poor living
conditions with malnutrition and lack of hygiene.
• medical help is not readily available.
• 5 million children die due to infectious diseases every year in developing
countries.
• 2 million deaths could be prevented by immunization.
The following immunizations are recommended for children:
• BCG (bacillus Calmet-Guerin): against tuberculosis; given intracutaneously
• DPT: against diphtheria, pertussis, tetanus; IM
• Polio (OPV): oral polio vaccine; PO
• Measles-vaccine; SC
• Hepatitis B; IM
Immunization schedule for children:
Right after birth
At 6 weeks
At 10 weeks
At 14 weeks
At 9 months
At 18 months
—
—
—
—
—
—
BCG
1. DPT, 1. polio, 1. hepatitis B
Measles
DPT – and polio booster
221
Immunizations
Childhood vaccination schedule for infants in developing countries
Vaccine
Age at
immunization
Notes
BCG (tuberculosis)
Birth
Not later than the 8 week of life
Polio
6, 10 and 14 weeks
+ 18 months
At birth, in endemic countries –
“zero dose”
Diphtheria, Tetanus,
Pertussis
6, 10 and 14 weeks
+ 18 months
Hepatitis B
6, 10 and 14 weeks
Measles
9 months
th
A second vaccination should
be provided (after 8 weeks)
Tetanus-immunization schedule for pregnant women:
Dose
Date
1
At first contact, e.g. for antenatal
No protection
care
2
At least 4 weeks later
3 years
3
At least 6 months later
5 years
4
At least 1 year later
10 years
5
At least 1 year later
Lifelong
222
Protection
List of Drugs
17.
LIST OF DRUGS
17.1. Binding Drug List for all Outpatient Projects
The following drug list is compiled by a group our experts who worked for
several months in different projects of the committee. This drug list was
updated in 2010 in accordance with guidelines of the World Health
Organization.
Occasionally certain drugs are not available locally (depending on the project
and supplier). This list is a standard which should be observed as close as
possible.
The following guidelines are binding for every doctor working one of our
projects.
Only drugs of group A – must be available at any time (a stock of drugs for
about 4 weeks). As soon as the stock of one of the drugs is going down it
must be ordered according to the local situation and supplier.
The binding drug list contains three groups of drugs:
Group A: drugs which are used on a regular base and which should be
stocked in large amounts
Group B: drugs for special indications which should be used occasionally and
should be stocked in small amounts
Group C: drugs used only exceptionally and should be ordered only on special
request
Drugs not on the list can be prescribed and ordered for selected patients after
discussion with the local coordinator.
We can order drugs for patients referred by us to a hospital or a local
specialist. We should use our own drugs if at all possible.
223
List of Drugs
ANAESTHETICS
Lidocaine amp
Ketamine amp
ANALGESICS/NON-STEROIDAL ANTIINFLAMMATORY DRUGS
Acetylsalicylic acid tab
Diclofenac tab
Ibuprofen tab
Paracetamol tab/susp
Hyoscine butylbromide tab/amp
Metamizol gutt
Tramadol gutt
ANTACIDS/REHYDRATION
Mixt. Magnesium Trisilicate tab
Ranitidine tab
ORS Sach
Omeprazol tab
ANTHELMINTICS/ANTIPROTOZOAL DRUGS
Mebendazole tab
Albendazole tab
Metronidazole tab/susp
Pyrantel-Pamoat susp
Praziquantel tab (Phil/Kenya)
Ivermectin tab
ANTIASTHMATIC DRUGS
Aminophyllin tab/amp
Salbutamol tab
Terbutaline susp
Beclomethasone inhaler
Prednisolone tab
224
List of Drugs
Salbutamol inhaler
ANTIBIOTICS/ANTIVIRAL DRUGS:
Amoxicillin tab/susp
Ciprofloxacin tab
Cotrimoxazole tab/susp
Doxycycline tab
Erythromycin tab/susp
Penicillin V tab/susp
Acyclovir tab
Chloramphenicol amp (tab/susp Phil)
Clindamycin tab
Cloxacillin tab/susp
nd
Cefachlor/Cefuroxime (or other cephalosporin 2 generation)
Azithromycin tab
Clarithromycin tab
ANTIDIABETICS
Glibenclamide tab
Metformin tab
Mixed insulin 30/70
ANTIEPILEPTICS
Carbamazepine tab
Phenytoin tab/susp
Sodium valproate tab/susp
ANTIFUNGAL DRUGS
Griseofulvin tab
Ketaconazol tab
225
List of Drugs
ANTIHISTAMINS/ANTIEMETICS
Diphenhydramine tab
Metoclopramide tab
Promethazine tab
ANTIMALARIAL DRUGS
Amodiaquine tab (Kenya)
Chloroquine tab/susp
Quinine tab (Kenya/Phil)
Fansidar tab (Kenya/Phil)
Mefloquine tab
Primaquine tab (India/Bangladesh)
ANTITUBERCULOSIS DRUGS
Ethambutol tab
Isoniazid tab
Pyrazinamide tab
Rifampicin tab
Streptomycin amp
CARDIOVASCULAR DRUGS
Bisoprolol/Metoprolol tab
Enalapril/Ramipril tab
Hydrochlorothiazide tab
Digoxin tab
Furosemide tab
Amlodipine/ Nifedipine ret. tab
ASS 100 tab
Isosorbide Mononitrate tab
Methyldopa tab
Spironolactone tab
DERMATOLOGICAL DRUGS
Benzyl benzoate 25% sol
226
List of Drugs
Clotrimazole 1% cream
Gentian violet 0.5% sol
Hydrocortisone 1% cream
Ichthammol 20% ointment
Povidone iodine 10% sol/ointment
Vaseline
Whitfield Ointment
Zink oxide 10% ointment
Framycetin (Soframycin) ointment
Nystatin 100 000 IU oral gel
Silver sulfadiazine ointment
Calamine lotion
GYNECOLOGICAL DRUGS
Cotrimoxazole pessaries/cream
Ergometrine amp
Oxytocin amp
OPHTHALMOLOGICAL/OTOLOGICAL PREPARATION/ NASAL DROPS
Chloramphenicol 0.5% drops (eyes, ears)
Gentamycin drops (eyes, ears)
Saline nose drops
Tetracycline 1% eye ointment
VITAMINS/IRON
Ferrous sulphate tab/susp
Folic acid tab
Multivitamin tab
Vitamin A caps
Iodized oil caps
Vitamin D susp, amp
Vitamin B tab
227
List of Drugs
17.2. Important Medicines and their Dosages
Children
Daily dosage
Adult
divided in doses
per day
Acetylsalicylic acid
300 mg
—
Acyclovir
Albendazole
400 mg
400 mg
Aminophylline
Amlodipine
Amoxicillin
100 mg
5 mg
500 mg
Artemether +
Lumefantrine
20 mg
120 mg
initial dose: 1 tab
(5-14 kg)
Azithromycin
500 mg
initial dose: 2 tab
(15-24 kg)
initial dose: 3 tab
(25-34 kg)
always repeat:
at 8,24,36,48, 60
hours
(≥2 mo ≤16 yrs)
single dose
Bisoprolol
Carbamazepine
5 mg
200 mg
Carbimazole
5 mg
Cefuroxime
Chloramphenicol
250 mg
250 mg
½ tab
(<2 yrs)
—
50-100 mg/kg
30 mg/kg
(>6 mo)
—
20 mg/kg
(up to 1200 mg/d)
—
3-4 x 1-2
1x ½ (CHD)
(+ children >12 yrs)
3x1
single dose
(+ children >2 yrs)
3 x 1-2
1 x 1-2
3 x 1-2
single dose
3
2
30 mg/kg
2
25-100 mg/kg
4
(high doses with typhoid
meningitis)
fever,
Chloroquine (Base)
150 mg
10 mg/kg, then
5 mg/kg
Ciprofloxacin
Clarithromycin
Cloxacillin
250 mg
250 mg
250 mg
30-40 mg/kg
day 1
after 6 hours,
day 2, 3
2
50 mg/kg
3-4
228
Daily dosage (tbl)
initial dose: 4 tab
repeat at 8, 24, 36,
48, 60 hours
(+ children >16 yrs,
≥35 kg)
2 tab single dose
1 x 1-2
20 mg/kg in 2 dvided
doses
initial dose:
10 mg (-30 mg) od
maintenance
dose:
2.5-15 mg od
2 x 1-2
3x1-3x4
(high
doses
with
typhoid
fever,
meningitis)
4 tab day 1, then
2 tab after 6 hours,
day 2,3
2 x 1-2
2 x 1-2
4 x 2-4
List of Drugs
Cotrimoxazole (TMP+SMZ)
8 mg/kg TMP
+ 40 mg SMZ
2
Diclofenac
Digoxin
—
—
—
—
3-6 mg/kg
—
—
50 mg/kg
5 mg/kg
(treatment)
3
—
—
3
1
2 mg/kg
(malnutrition)
0.5 mg/kg
(children <1 yr)
1
1-4 mg/kg
—
3-4 as needed
—
10 mg/kg
—
30 mg
(6-12 yrs)
30 mg/kg
(>7 kg)
5-10 mg/kg
200 mcg/kg
(>15 kg)
2
—
3
25 mg
0.25 mg
Diphenhydramine
50 mg
Doxycycline
100 mg
Enalapril
5 mg
Erythromycin
250 mg
Ferrous (elementary)
(Fe : Fe-Sulphate: 1 : 3)
Folic acid
5 mg
3
2
x
1
(160 mg TMP
+ 800 mg SMZ)
3 x 1-2
1x½-1
steady state
3x1
1-2 x 1
1x2-1x4
3-4 x 2
1 x 60 mg
(prophylaxis,
pregnant women)
1 x 120 mg
(treatment)
1 x 1 (treatment;
+ children > 1 yr)
1 x 1 (prophylaxis in
pregnancy)
1 tab as needed
1 x ½ - 3 x 1 (2/3
morning, 1/3 evening;
up to 2 tab morning, 1
tab nocte)
1x4-1x6
1x½-1x1
3x½ -3x1
3 x 2-4
1
1
1x3
1 x 200 mcg/kg
1-3
800 mcg
Furosemide
Glibenclamide
40 mg
3.5 mg
Griseofulvin
125 mg
Hydrochlorothiazide 25 mg
Hyoscine butylbromide 20 mg
Ibuprofen
200 mg
Isoniazid
Ivermectin
100 mg
Ketoconazole
200 mg
L-Thyroxin
Magnesium trisil.
Mebendazole
25 mcg
120 mg
100 mg
Mefloquine
250 mg
Metformin
Methyldopa
500 mg
250 mg
—
2 x 1 tab
(>2 yrs)
15 mg/kg, then
10 mg/kg after
6-12 hrs
(≥6 mo, >5kg)
—
—
Metoclopramide
Metoprolol
Metoprolol ret.
10 mg
50 mg
50 mg
—
—
—
—
single dose
single dose
—
—
—
—
1x1
1 x 3-5 mg/kg
(immunocompromised
patients)
1 x 2-4
4x1
2x1
3 - 2 (-1 >60 kg)
6-hourly intervals
1x1-2x2
2x1-3x2
(up to 3 x 4)
3x1
2x½-2
1x1-1x4
229
List of Drugs
Metronidazole
250 mg
200 mg
30 mg/kg
3
Niclosamide
500 mg
2 tab
(11-34 kg)
3 tab
(>34 kg)
—
single dose
single
Nifedipine ret.
Omeprazole
Paracetamol
Penicillin V 0.4 M =
Phenobarbital
Phenytoin
20 mg
20 mg
500 mg
250 mg
15 mg
100 mg
30 mg/kg
30-60 mg/kg
2-5 mg/kg
5 mg/kg
3-4
3-4
2
2
Praziquantel
600 mg
60 mg/kg
2-3
(S.japonicum)
40 mg/kg
1-2
(S.
mansoni,
haematobium)
5-10
mg/kg
(tapeworm)
single dose
5 mg
15 mg
25 mg
300 mg
5 mg
300 mg
4 mg
1-2 mg/kg
0.25 mg/kg
1 mg/kg
30 mg/kg
—
—
0.3-0.6 mg/kg
(2-6 yrs)
1
1
2-3
3
—
—
3
Sodium valproate
150 mg
20 mg/kg
2
Tinidazole
500 mg
(initially 5-10 mg/kg)
50-60 mg/kg
1
(≥6 yrs)
230
50 mg
Prophylaxis:
100 000 IU
200 000 IU
Treatment:
50 000 IU
100 000 IU
200 000 IU
25 000 IU
dose
—
Prednisolone
Primaquine
Promethazine
Quinine
Ramipril
Ranitidine
Salbutamol
Tramadol
Vitamin A
3 x 2, 2 x 2 (STD)
2 x 2 (STD), 2 x 4
(giardia)
1 x 4 single dose
1x1
2x1
4 x 1-2
4x2
1 x 2-5 mg/kg
5 mg/kg in 2 divided
doses
60 mg/kg in 2-3
divided doses
(S. japonicum)
40 mg/kg in 1-2
divided doses
(S.
mansoni,
haematobium)
5-10 mg/kg single
dose
(tapeworm)
as needed
1x1
1x1-3x2
3x2
1 x ½- 1 x 1
2x½-1x1
3-4 x ½
(+ children 6-12 yrs)
3-4 x ½ -1
20 mg/kg in 2 divided
doses
(initially 5-10 mg/kg)
1x4
3-4 x 1-2
6 -12 mo
> 1 yr
every 6 months
every 6 months
<6 mo
6-12 mo
> 1 yr
day 1, 2, 8
day 1, 2, 8
day 1, 2, 8
1 tab day 1, 2, 8
1 tab every week
(pregnant women)
List of Drugs
Suspensions
mg/5 ml
5 ml = 1 teaspoon
Albendazole
Amoxicillin
Chloramphenicol
200 mg
250 mg
125 mg
Chloroquine (Base)
150 mg
single dose
(children < 2 yrs)
50 mg/kg
3
—
25-100 mg/kg
4
(high doses with typhoid fever, meningitis)
10 mg/kg, then
day 1
5 mg/kg
after 6 hours,
day 2, 3
8 mg/kg TMP +
2
—
40 mg SMZ
50 mg/kg
3
—
5 mg/kg
1
(treatment)
2 mg/kg
1
(malnutrition)
½ drop/kg =
3
1-4 x 18-36 drops
10 mg/kg
(adults)
30 mg/kg
3
—
30 mg/kg
3-4
—
0.2 mg/kg
3
—
½ drop/kg =
can be repeated 1-4 x 20-40 drops
1.25 mg/kg
after 30-60 min
Do not exceed 4
doses in 24 hrs.
7 drops
1
Cotrimoxazole (TMP+SMZ)
Erythromycin
250 mg
Ferrous (elementary)
Fe : Fe-Sulphate: 1 : 3)
Metamizole
(1ml = 20 drops = 500 mg)
Metronidazole
125 mg
Paracetamol
250 mg
Terbutaline
1.5 mg
Tramadol
Vitamin D
(6 000 IU = 7 drops)
6000 IU
Always check, whether the concentration of tablets or suspension has
changed (e.g. chloroquine, erythromycin, metronidazole)!
Always check text for further information about the appropriate dosage!!
231
232
4
5
Adrenaline 1:10 000
Bradycardia, adjunct in
anaesthesia with ketamine,
organophosphate poisoning
Adults: 0.01-0.1 mg/kg,
children: 0.02 mg/kg
Adults: 1 amp (250 mg) up to tid,
avoid in children
Aminophylline 250 mg
Asthma
amp
Atropine 0.5 mg amp
Adults: 5-7 mg/kg slowly,
avoid in children
Aminophylline 250 mg
Asthma
amp
IV, IO
PO
IV, IO
IV, IO
Adults: titrate 0.5 ml boluses
according to response,
children: 0.01 mg/kg (=0.1 mL/kg
= 10 mcg/kg); titrate according to
response
Anaphylactic shock
By
nebulization
IM (SC)
0.5 mL/kg per dose (maximum dose:
5 mL) of 1:1000 solution
Anaphylaxis, anaphylactic
shock
Adrenaline 1:1000
(1 amp = 1 mg)
4
Application
Dosage
Adults: ½ amp (0.5 mg = 0.5 mL),
children: 0.01 mg/kg (=0.01 mL/kg)
Repeat according to response
Adrenaline 1:1000
Croup
(1 amp = 1 ml = 1 mg)
Indication
Name
Amount
17.3.1. Emergency drugs
17.3. Emergency Kit
List of Drugs
Gelafundin 500 ml
Glucose 40% 20 ml
2
1
1
Adults: 20 ml slowly, avoid in children
Adults, children: 0.5-1 mg/kg
Pulmonary oedema,
congestive cardiac failure,
ascites, fresh water
drowning
Furosemide 20 mg
amp
2
Loss of consciousness of
unknown origin,
hypoglycaemia
Adults, children: 1-2 mg/kg slowly up
to tid prn
Allergy, anaphylaxis,
nausea, sedation
Diphenhydramine
50mg amp
2
Adults: 30 ml/kg; avoid in children
Adults, children > 15 kg: 10 mg (2
rectal tubes),
children < 15 kg: 5 mg (1 rectal tube)
Diazepam 5 mg rectal Childhood seizure; avoid in
tube
croup
2
Shock, low blood volume
Adults: starting with 5-10 mg titrate
slowly in 5 min intervals (15 – 20 – 25
mg etc; maximum dose: 60 mg),
IV, IO
children: 0.3 mg/kg, then give 0.1
mg/kg according to response
Anxiety, panic attacks,
Diazepam 10 mg amp epileptic fit, acute coronary
syndrome
IV, IO
IV, IO
IV, IO
233
IV, IO, IM,
PO
PR
IV, IO
Adults, children: 0.1 mg/kg slowly
IV, IO
Dexamethasone 8 mg
Anaphylaxis, thyrotoxicosis
amp
Adults: 0.05-0.1 mg/kg slowly
2
Drug-induced
extrapyramidal symptoms,
parkinsonism
Biperiden 5 mg amp
2
List of Drugs
234
1
IV, IO
Adults: 0.5 mg/kg slowly,
children: 1 mg/kg slowly
Lidocaine 2% 50 ml
(1 ml = 20 mg)
Ventricular tachycardia,
ventricular fibrillation
(electric shock), ventricular
arrhythmias
Ketamine 500 mg
amp
IV, IO
IV, IO
IM, PO
Ketamine 500 mg
amp
Adults, children:
0.25-0.5-1 mg/kg
IV, IO, IM
Adults, children: 2 mg/kg
or 5-6 mg/kg
repeat after 15-20 min.
Sedation
Ketamine 500 mg
amp
2
Adults: 0.5 mg/kg slowly up to tid prn;
avoid in children
Anaesthesia
Analgesia
Hyoscine
butylbromide 20 mg
amp
2
Adults: 2 mg/kg,
children: 4-8 mg/kg stat, then 2 mg/kg IV, IO,IM
up to qid prn
SL
IV, IO
IV, IO
IM, PO
Biliary colic, ureteric colic,
acute abdomen
Hydrocortisone
100mg amp
4
1-2 puffs
Children: 2.5 mL/kg slowly
Adults, children: 1-1.5 mg/kg
or 4-5 mg/kg
Anaphylaxis, allergy,
bronchial asthma, croup
GTN-spray
Loss of consciousness of
unknown origin,
hypoglycaemia
Acute coronary syndrome,
hypertensive crisis
1
Glucose 10%
List of Drugs
Analgesia, acute coronary
syndrome
Induction or enhancement of
4 IU in 500 ml Ringer’s Lactate
labour; postpartum
solution
haemorrhage
Allergy, anaphylaxis,
nausea, sedation
Intravenous infusion, shock,
volume depletion
Nalbuphine
10 mg amp
Oxytocin 10 IU amp
(store under
refrigeration)
Promethazine 50mg
amp
Ringer’s Lactate
solution 500 ml
10
2
2
2
2
Adults: 1 mg/kg
children: 0.25-1 mg/kg
up to tid prn
Adults: 50 mL/kg,
children: 10-20 mL/kg,
repeat prn
Adults, children: 0.2 mg/kg,
repeat prn every 3-6 hours
Adults, children ≥12 yrs:
5-10 mg tid prn
Nausea, vomiting, migraine
Metoclopramide
10 mg amp
5
1 amp
Uterine atony (postpartum)
Methylergometrine
0.2 mg amp (store
under refrigeration,
protect from light)
List of Drugs
IV, IO
235
IV, IO, PO
IV-infusion
IV, IO, IM,
SC
IV, IO, IM
SC
Bronchial asthma, croup,
status asthmaticus
Bronchial asthma, status
asthmaticus
Analgesia
Salbutamol inhaler
Salbutamol nebules
2.5 mg
Tramadol 400 mg
amp
236
IM:
IO:
IV:
PO:
SC:
SL:
intramuscular
intraosseous
intravenous
oral
subcutaneous
sublingual
Applications (abbreviation):
1
Inhalation
By
nebulization
IV, IO, IM,
PO
Adults, children: 2-4 puffs, preferably
with spacer,
repeat prn after 20 min
Adults, children > 5yrs: 2.5-5 mg,
children ≤ 5yrs: 2.5 mg
Repeat prn after 20 min
Adults, children ≥ 12 yrs:
2 mg/kg,
children 1-11 yrs: 1-2 mg/kg
up to tid prn
List of Drugs
List of Drugs
17.3.2. Emergency equipment
Abbocath neddles
(G 16, 20, 24 – each 2)
Alcohol 70% bottle
Ambubag
Butterfly needles
(G 21, 23, 25 – each 2)
Catgut
(2-0, 3-0, 4-0 – each 5)
Flashlight with batteries
Gloves, nonsterile pairs
Guedel tubes
(child: 1, adult: 1)
Glucosticks pack
IV tubing
KY jelly
Masks
(child: 1, adult: 1)
Nasogastric tubes
(size Fr 10, 14 – each 1)
Needles
(G 20, 22, 25 – each 4)
Roller bandage
Rolls of tape
(small: 1, broad: 1)
Saw for ampules
Scissors
Silk
(2-0, 3-0 – each 3)
Sterile OS pack
Syringes
(1 ml, 2 ml, 5 ml, 10 ml – each 3)
Tongue depressor
Tourniquet
Urine catheters
(size 12, 14, 16)
6
1
1
6
15
15
1
3
2
1
5
1
2
2
12
1
2
2
2
6
1
12
10
2
3
237
List of Drugs
17.4. Drugs during Pregnancy and Breastfeeding
Classification of drugs in pregnancy and breastfeeding:
+
first line agent
usually safe in pregnancy and breast-feeding; use
only if non-drug treatment presumably not effective
±
second line agent
only indicated if other treatment is not effective;
often insufficient information available about
pregnancy and breastfeeding
S
single dose only
single dose or low dose for 1-3 days
(–) potentially toxic
for embryo, fetus, newborn or breastfed infant; use
only when potential benefit greater than the risk
taken
–
probably teratogenic or fetotoxic, possible adverse
effects during breastfeeding or the benefit to the
mother not outweighing the risk to the fetus
238
contra-indicated
List of Drugs
First
trimester
st
th
-12
(1
week)
Second/
third
trimester
th
(> 13 week)
Short
before
term/
during
labour
Breastfeeding
±, S
(–)
+
+
(–)
+
(–)
+
+
±, S
–
+
+
+
+
±
+
+
–
–
+
+
+
+
±
+
+
±, S
+
+
+
+
+
+
+
+
(–)
±
±
±
Beclomethasone (inhaler)
+
+
+
+
+
+
–
+
+
Benzyl benzoate (topical)
+
+
+
Biperiden
+
+
(–)
–
+
(–)
+
(–)
+
+
+
+
(–)
+
+
+
–
+
+
+
±
–
+
(–)
+
+
+
+
+
+
–
+
+
(–), S
–
+
+
(–)
±
–
+
(–)
+
+
+
+
+
+
–
+
+, S
(–), S
–
+
–
+
+
+
– on breast
+
+
+
+
+
–
–
–
+, S
–
–
+
–
+
+, S
+
(–)
+
Drug
Acetylsalicylic acid
ACE-inhibitors
Acyclovir
Adrenaline
Albendazole
Aminophylline
Amlodipine
Amoxicillin
Antacids
Artemether
Lumefantrine
Atropine
+
Azithromycin
Bisoprolol
Carbamazepine
Carbimazole
Cefuroxime
Chloramphenicol
Chloroquine
Ciprofloxacin
Clemastine
Clindamycin
Clarithromycin
Cloxacillin
Cotrimoxazole
Dexamethasone
Diazepam
Diclofenac
Diethylcarbamazine
Digoxin
239
List of Drugs
Diphenhydramine
Doxycycline
Enalapril
Ethambutol
+
±
(–)
+
–
+
–
–
+
–
Ergometrine
+
–
–
+
–
+
–
+
+
(–)
(postpartum
possible with atonic
uterus)
Gentamycin
+
+
+
+
±
–
+
+
+
+
±
–
+
+
+
+
±
–
+
+
+
+
±
+
Glibenclamide
±
±
±
(–)
+
(–)
+
±
+, S
(–), S
+
+
+
–
+
±
+
+
(–)
+
±
+, S
(–), S
+
+
+
–
+
±
+
+
–
–
+
+, S
+
+
+
+
–
+
±
+
(–)
(–)
(–)
+
+
±
+
+
+
+
(–)
(–)
±
+
+
+
+
+
+
(–)
(–)
±
+
+
(–)
+
+
+
–
(–)
+
+
(–), S
+
(–), S
+
+
+
(–)
+
Erythromycin
Ethambutol
Ferrous sulphate
Folic acid
Furosemide
+
(–)
H2–receptor antagonists
+
Hydrochlorothiazide
±
Hyoscine butylbromide
+, S
Ibuprofen
+
Insulin
+
Isoniazid
+
Isosorbide Mononitrate
+
Ivermectin
–
Ketamine
+
Ketoconazole
±
Lidocaine
(local +
Glyceryl trinitrate
Griseofulvin
anaesthetic)
Mebendazole
Mefloquine
Metamizole
Metformin
Methyldopa
Metoclopramide
Metoprolol
Metronidazole
Multivitamins
(vit. A < 6 000 IU/d)
Nalbuphine
240
List of Drugs
Niclosamide
Nifedipine
Nystatin
Omeprazole
Oxytocin
+
(–)
+
±
–
+
±
+
+
–
+
±
+
+
+
+
+
+
+
+
(postpartum)
+
Penicillin V
+
Phenobarbital
(–)
Phenytoin
(–)
Povidone iodine (topical)
+
Praziquantel
±
Prednisolone
+
Primaquine
–
Promethazine
+
Pyrazinamide
+
Quinine
–
Ramipril
(–)
Ranitidine
+
Rifampicin
±
Salbutamol (inhaler)
+
Salbutamol p.o.
+
Silver
sulfadiazine +
+
+
(–)
(–)
(–)
+
+
–
+
+
±
–
+
+
+
+
+
+
+
(–)
(–)
(–)
+
+
–
+
+
–
–
+
+
+
+, S
(–)
+
+
+
+
–
+
+
–
+
+
+
+
–
+
+
+
(–)
(–)
–
+
±
(–)
(–)
–
+
±
(–)
–
+
–
±
+
–
+
±
(–)
–
+, S
–
±
+
–
+
±
+
+
+
–
(–)
+
+*
+
+
Paracetamol
(topical)
Sodium valproate
Streptomycin
Terbutaline
Tetracycline (topical)
Tinidazole
Tramadol
Vit. A > 10 000 IU/d
Vit. B
Vit. D
* Vitamin A 200 000 IU can be given to mothers within 8 weeks of delivery (WHO
recommendations)
241
Abbreviations
18.
ABBREVIATIONS
They should not be learned by heart! They are mentioned to give you an idea
what you can find in a chart or a letter and to help you to understand.
AC
Adm
AF
AFB
am
ARI
ASA
AXR
BBB
BE
bid
BM
BP
BS
BUN
Bx
C
CA
CAD
Caps
CBC
CC
CCF/CHF
CHD
CI
CNS
C/o
COPD
CRF
C&S
CSF
CVA
CXR
D
D&C
242
before meals
admission
atrial fibrillation
acid fast bacilli
in the morning
acute respiratory tract infection
acetylsalicylic acid
abdominal x-ray
bundle branch block
barium enema
twice daily (bis in die)
bowel movement
blood pressure
bowel sounds
blood urea nitrogen
biopsy
with
carcinoma
coronary artery disease
capsule
complete blood count
cough and cold
congestive cardiac/heart failure
congenital heart disease
contraindication
central nervous system
complaining of
chronic obstructive pulmonary disease
chronic renal failure
culture and sensitivity
cerebrospinal fluid
cerebrovascular accident
chest x-ray
day (d) or diarrhoea (D)
dilatation and curettage
Abbreviations
D&V
DC
DCT
DF
DHF
DM
DOB
DSS
Dx
EENT
ENT
EPH
EOR
ESR
FB
FBC
FBS
F/U
FUO
Fx
GIT
GUT
H
HAART
Hb
HBP
Hct
Ht
Hx
I&D
ICS
ID
IM
IO
IUD
IV
IVP
KUB
LBM
LBP
LLE
diarrhoea and vomiting
differential count
diagnostic counselling and testing
dengue fever
dengue haemorrhagic fever
diabetes mellitus
date of birth
dengue shock syndrome
diagnosis
eye, ear, nose and throat (department)
ear, nose and throat (department)
oedema, proteinuria, hypertension
error of refraction
erythrocyte sedimentation rate
foreign body
full blood count
fasting blood sugar
follow-up
fever of unknown origin
fracture
gastrointestinal tract
genito-urinary tract
hour
highly active antiretroviral therapy
haemoglobin
high blood pressure
haematocrit
height
history
incision and drainage
intercostal space
intradermal
intramuscular
intraosseous
intrauterine device
intravenous
intravenous pyelogram
kidney, ureter, bladder (x-ray)
loose bowel movement
lower back pain
left lower extremity
243
Abbreviations
LLL
LLQ
LMP
LN
LOC
LP
LUL
LUQ
LVF
MUAC
ND
No
NPO
NS
NSAID
O&P
OB-GYN
od
OE
OM
OPD
ORS
PEP
PID
pm
PMB
PMH
PO
PR
prn
PTA
PTB
PUD
PUO
PVD
qid
RA
RBC
RBS
RLE
RLL
244
left lower lobe
left lower quadrant
last menstrual period
lymph node
loss of consciousness
lumbar puncture
left upper lobe
left upper quadrant
left ventricular failure
mid-upper arm circumference
not done
number
nil by mouth (nihil per os)
normal saline
non-steroidal anti-inflammatory drug
ova and parasites
obstetrics and gynaecology
once daily
otitis externa
otitis media
outpatient department
oral rehydration solution
post-exposure prophylaxis
pelvic inflammatory disease
in the afternoon
postmenopausal bleeding
past medical history
per os
per rectum; pulse rate
as required
prior to admission
pulmonary tuberculosis
peptic ulcer disease
pyrexia of unknown origin
peripheral vascular disease
four times a day (quattuor in die)
rheumatoid arthritis
red blood count
random blood sugar
right lower extremity
right lower lobe
Abbreviations
RLQ
r/o
RR
RUE
RUL
RUQ
Rx
SC
S/e
SL
SMP
SOB
Stat
STD
TCB
tid
TLC
UGI
US
URTI
UTI
V
VCT
V/E
WBC
Wt
right lower quadrant
rule out
respiratory rate
right upper extremity
right upper lobe
right upper quadrant
prescription
subcutaneous
side effects
sublingual
smear for malarial parasites
shortness of breath
straight away
sexually transmitted disease
to come back
three times a day (ter in die)
tender loving care
upper GI series
ultrasound
upper respiratory tract infection
urinary tract infection
vomiting
voluntary counselling and testing
vaginal examination
white cell count
weight
245
Dictionary German – English
19.
DICTIONARY GERMAN – RNGLISH
To help our colleagues with the translation of some of the most important
terms.
A
Ablauf
Abort
Abstillen
Abstrich
Abwehrspannung
Ambulant
Anfall
Angina
Arzneimittel
Atemgeräusch
Atemgymnastik
Atmen, vesikulär
Attest
Aufnahme (stationär)
Augenbraue
Augenlid
Ausfluss
Ausrenkung
Ausschlag
Auswurf
drainage
abortion, miscarriage
weaning
smear
guarding
outpatient
heart: attack; epileptic: seizure, fit, convulsion
(generalized)
sore throat
drugs
breath sounds
respiratory exercises
vesicular breath sounds
medical certificate
admission
eyebrow
eyelid
discharge
dislocation
rash, eruption
sputum, phlegm
B
Bandwurm
Bauch
Becken
Beschwerden
Bewußtlosigkeit
Bewußtseinsstörung
Bindegewebe
Bissverletzung
Blähung
Blase
Blasensprung
tapeworm
belly, abdomen
pelvis
complaints
unconsciousness, loss of consciousness
impaired consciousness
connective tissue
bite injury
flatulence, wind
blister (derm.), bladder (urol.)
rupture of the membranes
246
Blutausstrich
Blutbild
Blutprobe
Blutung
Brandwunde
Brechdurchfall
Brechreiz
Brille
Bruch
Brummen
Brustkorb
Brustwarze
BWS
blood smear, blood slide
blood count
blood sample, blood specimen
bleeding, haemorrhage
burn
diarrhoea and vomiting
nausea
spectacles, eye glasses
hernia (inguinal), fracture (bone)
rhonchi
chest
nipple
thoracic spine
D
Darm
Darmgeräusche
Daumen
Doppelsehen
Dosierung
Dumpf
Durchblutungsstörung
bowel, intestine
bowel sounds
thumb
double vision
dosage
dull
circulatory disorder
E
Eierstock
Einlauf
Einmal...
Einschnitt
Eisenmangelanämie
Eiter
Ellenbogengelenk
Empfängnisverhütung
Entbindung
Entfernung
Entlassung
Entlastung
Erblindung
Erguss
Erkältung
Erreger
Erste Hilfe
ovary
enema
disposable
incision, cut
iron deficiency anemia
pus
elbow joint
contraception, birth control
delivery
removal (chir.)
discharge (from hospital)
relief
loss of vision
effusion
cold
causative agent
first aid
247
Erstickung
Ertrinken
Esslöffel
suffocation, asphyxiation
drowning
tablespoon
F
Fehlgeburt
Ferse
Fieberkrämpfe
Frösteln
Frühgeburt
Fußknöchel
Fußpilz
miscarriage
heel
febrile convulsions
shiver
preterm labour
ankle
tinea pedis, athlete’s foot
G
Gallenblase
Gallenkolik
Gallenstein
Gallenwege
Gaumen
Gebärmutter
Gebiss, künstliches
Gebühr
Geburt
Geburtswehen
Gedeihstörung
Gehgips
Gehirnerschütterung
Geisteskrankheit
Gelbsucht
Gelenkerguss
Gesäß
Gesäßhälfte
Geschlechtskrankheit
Geschwür
Geschwulst
Gewichtsverlust
Gewichtszunahme
Gicht
Giemen
Gipsschiene
Gipsverband
gallbladder
biliary colic
gallstone
bile ducts
palate
uterus, womb
denture
fee, charge
delivery
contraction
failure to thrive
walking cast
concussion
mental disorder
jaundice
joint effusion
bottom
buttock
sexually transmitted disease, venereal disease
ulcer, sore
tumor
weight loss
weight gain
gout
wheezes
plaster splint
plaster cast
248
Gliedmaßen
Grippe
Gürtelrose
Gurgeln
limbs
flu, influenza
shingles, herpes zoster
gargle
H
Haarausfall
Hämorrhoiden
Hals
Halsschmerzen
Handgelenk
Handschuh
Harnblase
Harnverhalt
Hasenscharte
Hautausschlag
Hauterkrankung
Hebamme
Heiserkeit
Herzgeräusch
Herzinfarkt
Herzinsuffizienz
Herzklappenfehler
Herzton
Heuschnupfen
Hoden
Hüftgelenk
Husten, produktiver
HWS
loss of hair, alopecia
hemorrhoids, piles
neck
sore throat
wrist
glove
bladder
urinary retention
harelip
rash
skin disease
midwife
hoarseness
heart murmur
heart failure
valvular defect
heart sound
hay fever
testicles
hip joint
productive cough
cervical spine
I
Impfstoff
Impfung
Ischialgie
vaccine
vaccination
sciatica, lumbago
J
Jodmangelstruma
Juckreiz
iodine deficiency goitre
itch(ing)
249
K
Kaiserschnitt
Kehle
Kehlkopf
Keuchhusten
Kiefer
Kinderkrankheit
Kinn
Klagen
Kleinkind
Knöchelödem
Kopfverletzung
Krätze
Krampf
Krampfadern
Krankenblatt
Krankentrage
Krankheit
Krebs
Kreislaufversagen
Kreuzschmerzen
Krücke
caesarean section
throat
larynx
whooping cough
jaw
childhood disease
chin
complaints
toddler
ankle oedema
head injury
scabies
spasm, cramp
varicose veins, varices
medical record
stretcher
illness, disease
cancer
circulatory failure
lower back pain
crutch
L
Lähmung
Lebendimpfstoff
Leistenbruch
Lungenentzündung
Lymphknoten
paralysis, palsy
live vaccine
inguinal hernia
pneumonia
lymph node
M
Magensonde
Mandeln
Milbe
Milz
Missbildung
Müdigkeit
Mundsoor
Muskelriss
nasogastric tube
tonsils
mite
spleen
malformation
fatigue
oral thrush
ruptured muscle
250
N
Nabel
Nabelbruch
Nachtblindheit
Nackenstarre
Nadelstichverletzung
Nässend
Naht
Narbe
Nasenbluten
Nasenflügelatmen
Nasenloch
Nebenniere
Nebenwirkung
Nervenzusammenbruch
Niere
Nierenstein
Nierenkolik
Niesen
Nisse
Nüchtern
navel, umbilicus
umbilical hernia
night blindness
stiff neck
needle-stick injury
weeping
suture
scar
epistaxis
nasal flaring
nostril
adrenal gland
side effect
nervous breakdown
kidney
renal stone
renal colic
sneezing
nit
fasting
O
Oberlid
Oberschenkel
Oberschenkelhals
Ödem
Ohnmacht
Ohrenschmalz
Ohrenschmerzen
upper lid
thigh
neck of femur
oedema
fainting
earwax, cerumen
ear-ache
P
Pflaster
Placentalösung
Pleurareiben
Pleuritis
Punktion
plaster, tape
abruption of placenta
pleural rub
pleurisy
puncture
Q
Quetschung
contusion, bruise
251
R
Rachitis
Rasselgeräusche
feucht/ trocken
Reizhusten
Rezidivierend
Rheuma
Röntgen
Röteln
Rückenmark
Rückfall
Ruhr
rickets
rales
moist, crackling/ dry
dry cough
relapsing, recurrent
rheumatism
x-ray
rubella, German measles
spinal cord
relapse
dysentery
S
Säugling
infant
Salbe
ointment
Saugen
sucking
Schädel
skull
Schälen
peeling
Scharlach
scarlet fever
Scheidenausfluß
vaginal discharge
Schere
scissors
Schiene
splint
Schlaff
floppy
Schlaflosigkeit
insomnia
Schlaganfall
stroke, cerebro-vascular accident
Schleimig
mucus
Schluckauf
hiccup
Schlucken
swallowing
Schlüsselbein
collarbone, clavicle
Schmerz
pain
Schmierinfektion
smear infection
Schnittwunde
cut
Schnupfen
common cold
Schürfwunde
graze, abrasion
Schüttelfrost
chills, rigor
Schwäche
weakness
Schwangerschaft
pregnancy
Schwindel
dizziness, vertigo
Sehne
tendon
Sehnenscheidenentzündung
tenosynovitis
252
Sodbrennen
Soor
Speichel
Spätreaktion
Spatel
Spirale
Sprache, verwaschene
Sprunggelenk
Stanze
Stauschlauch
Stich
Stichwunde
Stillen
Stimmband
Stirn
Stuhl
Stuhlerbrechen
Stuhlgang
Sucht
Synkope
heartburn
thrush
saliva
delayed reaction
spatula
IUD (intrauterine device)
slurred speech
ankle joint
punch
tourniquet
stitch, prick
stab wound
breast feeding
vocal cord
forehead
stool, faeces
faecal vomiting
defecation
addiction
syncope, fainting
T
Taille
Taub
Tinea
Tollwut
Totgeburt
Trinkschwäche
Trommelfell
Tropf
Typhus
waist
deaf, numb
ringworm
rabies
stillbirth
sucking weakness
eardrum, tympanic membrane
drip
typhoid fever
U
Übelkeit
Unfall
Unterarm
Unterschenkel
nausea, sickness
accident
forearm
lower leg
V
Vene
vein
253
Verband
Verbrennung
Verbrühung
Verdauung
Vergewaltigung
Vergiftung
Verlaufskontrolle
Verschreibung
bandage, dressing
burn
scald
digestion
rape
poisoning, intoxication
follow-up
prescription
W
Wachstumsverzögerung
Wade
Wange
Warze
Watte
Wehen
Windeldermatitis
Windpocken
Wirbelsäule
Würmer
Wundschorf
growth retardation
calf
cheek
wart, verruca
cotton wool
labour
nappy rash
chickenpox
spinal column
worms
scab
Z
Zahnfleisch
Zahnfleischentzündung
Zahnpflege
Zahnschmerz
Zahnstein
Zehe
Zerrung
gum
gingivitis
dental care
toothache
calculus
toe
distorsion, sprain
254
Bibliography
20.
BIBLIOGRAPHY
British National Formulary, No. 56, September 2008.
Cook, G. C., Manson’s Tropical Diseases, W.B. Saunders Company Ltd., 21
edition, 2003.
st
Eddleston, M.; Davidson, R.; Wilkinson, R.; Pierini, S.: Oxford Handbook of
nd
Tropical Medicine. Oxford University Press, 2 edition, 2005.
Fitzgerald, D. F.; Kilham H. A.: Croup: Assessment and Evidence-based
Management. Medical Journal of Australia, 2003; 179: 372-377.
Friese, K.; Mörike,K., Neumann,G.; Windörfer, A.: Arzneimittel in
Schwangerschaft und Stillzeit. Wissenschaftliche Verlagsgesellschaft mbH, 6.
Auflage, Stuttgart, 2006.
Herold, G., Innere Medizin, Official site: www.herold-innere-medizin.de, 2010.
Médecins sans Frontières, Clinical Guidelines, 2010.
Rote Liste 2010, Editio Cantor Verlag, Aulendorf/ Württ.
Scholz,H.; Belohradsky, B. H.; Bialek, R.; Heininger, Kreth, H.W.; Roos, R.:
DGPI-Handbuch. Deutsche Gesellschaft für Pädiatrische Infektiologie e.V.,
Georg Thieme Verlag, 5. Auflage, Stuttgart, 2009.
UNAIDS - The Joint United Nations Program on HIV/AIDS: Report on the
Global AIDS Epidemic, Geneva, 2009.
Working Group of the Resuscitation Council (UK): Emergency treatment of
anaphylactic reactions, Guidelines for healthcare providers, London, January
2008.
255
Bibliography
World Health Organization (WHO):
Management of the Child with a Serious Infection or Severe Malnutrition,
WHO, 2000.
Hospital Care of Children, WHO 2005.
WHO Child Growth Standards and the Identification of Severe Acute
Malnutrition in Infants and Children, WHO and UNICEF 2009.
Current Strategies for Human Rabies Pre- and Post-exposure Prophylaxis,
WHO 2010.
Implementing New Recommendations on the Clinical Management of
Diarrhoea, WHO 2006.
Treatment of Diarrhoea, A Manual for Physicians and other Senior Health
Workers, WHO 2005.
Background Document: The Diagnosis, Treatment and Prevention of Typhoid
Fever, WHO 2003.
Guidelines for the Control of Shigellosis, including Epidemics due to Shigella
Dysenteriae Type 1, WHO 2005.
Guidelines for the Treatment of Malaria, WHO 2006.
Guidelines for the Management of Sexually Transmitted Infections, WHO
2003.
Guidelines for the Treatment of Malaria, WHO 2006.
The Global Initiative for Asthma (GINA):
GINA Report, Global Strategy for Asthma Management and Prevention,
December 2009.
Global Strategy for the Diagnosis and Management of Asthma in Children 5
years and Younger, May 2009.
256
Bibliography
Pocket Guide for Asthma Management and Prevention, December 2010.
The Global Initiative for Chronic Obstructive Lung Disease (COLD):
Global Strategy for the Diagnosis, Management and Prevention of Chronic
Obstructive Pulmonary Disease, Updated 2009.
Pocket Guide to COPD Diagnosis, Management and Prevention, updated
2010.
Websites:
www.who.int
www.cdc.gov
www.goldcopd.org
www.ginasthma.com
www.uptodate.com
www.emedicine.medscape.com
257
Index
21.
INDEX
Abdomen
acute ................... 35, 67, 106, 164
distended ................................ 105
Abdominal thrust .............................. 45
Abscess ......................................... 174
breast ...................................... 169
dental ................................ 40, 196
liver........................ 28, 83, 84, 105
Acid fast bacilli............................ 66, 68
Acute laryngo-tracheobronchitis ....See
Croup
Acute respiratory infections ............. 49
AIDS......................................... 69, 154
Allergy ...................................... 55, 172
Amoebiasis ...................................... 82
Anaemia........................... 31, 107, 160
Anaphylaxis/anaphylactic shock ...... 45
Antenatal/postnatal care ................ 162
Appendicitis ........... 102, 105, 152, 165
Arthritis............................. 78, 143, 173
Ascaris ............................... 50, 74, 104
Asthma, bronchial ..................... 55 - 64
Athlete’s foot ................................... 179
BCG .................................. 68 - 70, 221
Bites .................................See Wounds
Bitot’s spot.............................. 100, 129
Blackwater fever ............................ 120
Blood transfusion ............. 34, 119, 160
Boils ................................ See Abscess
Bronchitis ......................... 50, 107, 156
Bronchopneumonia................ 128, 134
Brugia malayi ................................. 114
Burns ............................................. 184
Cachexia ................................ 112, 118
Campylobacter enterocolitis ...... 76, 78
Candidiasis
thrush .............................. 156, 180
vulvovaginal ............................ 148
258
Caries spine ..................................... 67
Cataract.................................. 188, 191
Cellulitis.......................................... 176
Cerumen ........................................ 196
Chancroid......................... 146, 65, 151
Chest pain ................................ 42, 217
Chlamydial infection ....... 143, 149, 153
Cholera....................................... 76, 85
Chronic obstructive pulmonary disease
(COPD).................................. 55, 63
Clostridium perfringens .................... 76
Coma................ 67, 120, 165, 203, 205
Common cold ................................... 50
Coniotomy ........................................ 54
Conjunctivitis .................. 143, 144, 188
Contact dermatitis
allergic ..................................... 171
irritant ...................................... 171
Cough............................................... 21
Cretinism ........................................ 198
Croup ............................................... 52
Cysticercosis .......................... 110, 206
Daily Fetal Movement Count (DFMC)
..................... See Fetal movements
Deafness .......... 81, 132, 146, 194, 195
Dehydration...................................... 89
Dengue fever.................................. 125
Dengue haemorrhagic fever (DHF) 126
Dengue shock syndrome ............... 126
Dermatitis ....................... 143, 156, 171
Diabetes mellitus.. 31, 39, 42, 140, 203
Diarrhoea ......................................... 75
with fever and blood .................. 76
with fever, without blood............ 79
without fever, with blood............ 82
without fever, without blood....... 84
DOTS ............................................... 69
Dysentery ......................See Diarrhoea
Index
Dyspnoea............. 23, 42, 55, 105, 217
E. coli ....................... 88, 131, 138, 153
enteritis...................................... 76
enterotoxicogenic ...................... 84
haemorrhagic coliti .................... 76
Eclampsia ...................... 163, 165, 214
Eczema .......................................... 171
atopic ...................................... 172
superinfected .................. 171, 173
Elephantiasis ................... See Filariasis
Emergencies .................................... 41
Emergency
drugs ....................................... 232
equipment ............................... 237
Encephalitis ............. 31, 109, 129, 134
Endocarditis ................................... 143
Enterobius vermicularis ................. 102
Epigastric pain ......... 71, 104, 107, 113
Epilepsy ......................................... 206
Epistaxis ........................ 118, 125, 134
Erysipelas ...................................... 175
Espundia ................ See Leishmaniasis
Failure to thrive ............ 33, 68, 94, 138
Fatigue ............................................. 25
Fetal movements ........................... 163
Fever................................................ 27
Filariasis......................................... 114
Fontanelle, bulging ........................ 131
Food poisoning .......................... 31, 76
Fundus ........................................... 168
Fungal infections.................... 156, 178
Gastritis............................................ 71
Gestational Diabetes ..................... 205
Giardiasis ......................................... 85
Glomerulonephritis................. 139, 173
Glucose-6-phospate dehydrogenase
(G6PD) deficiency ............... 35, 123
Goitre ............................................. 198
Gonorrhoea.................... 142, 149, 152
Graves’ disease ..................... 199, 200
Gumma .......................................... 145
Haemophilus influenzae ..... 50, 51, 53,
131
Haemoptysis .............. 21, 65, 108, 134
Haemorrhage ................. 131, 206, 219
antepartum .............................. 167
postpartum .............................. 168
subconjunctival........................ 134
Headache..... 20, 31, 40, 125, 131, 165
Heimlich manoeuvre ........................ 45
Helicobacter pylori............................ 72
Helminthiasis.................................. 102
Hepatitis ................................... 73, 209
Hepatitis A ................................. 73
Hepatitis B ................................. 73
Hepatitis C................................. 73
Hepatitis D................................. 74
Hepatitis E ................................. 74
Hepatomegaly ........ 28, 37, 83, 95, 126
Herpes.................................... 129, 131
genital...................... 148, 150, 152
zoster
156
Highly Active Antiretroviral Therapy
(HAART).................................... 159
HIV ........................... 69, 154, 170, 180
Hookworm .......................... 32, 50, 106
Hydronephrosis .............................. 112
Hydrophobia................................... 135
Hypertension .......... 139, 164, 166, 214
Hyperthyroidism ............... 25, 199, 216
Hypoglycaemia...... 120, 123, 205, 206,
220
Hypothyroidism .............................. 199
Immunization...... 69, 87, 130, 135, 221
Impetigo ................................. 139, 173
Inguinal bubo.................................. 153
Intraosseous infusion ....................... 48
Iron deficiency anaemia ... 32, 104, 107
Jaundice............. 26, 36, 105, 120, 198
Kala-Azar ...............See Leishamniasis
Katayama fever .............................. 112
Keratitis .................. 100, 115, 146, 189
Keratomalacia ........................ 100, 129
Kwashiorkor ............................... 95, 97
Leishmaniasis ................ 117, 157, 178
Leprosy .................................. 127, 181
Liver abscess .................. See Abscess
Loss of
consciousness..... 39, 41, 206, 219
weight .. 68, 89, 118, 156, 199, 203
259
Index
Lower respiratory tract infection....... 50
Lumbar puncture............................ 132
Lymphadenopathy 118, 125, 144 -148,
156
Lymphogranuloma venereum ........ 147
Malaria ............................... 28, 32, 118
cerebral ............. 42, 120, 132, 206
quartan .................... 119, 122, 140
tertian ...................... 119, 122, 123
Malnutrition ...................................... 94
Mantoux test .............................. 68, 70
Marasmus ........................................ 95
Mastitis........................................... 169
Mastoiditis .............................. 195, 196
Measles ..................... 68, 82, 100, 128
Meningitis......... 81, 109, 130, 157, 206
Middle upper arm circumference ..... 96
Myalgia .......................................... 125
Nairobi eye............................. 171, 172
Nausea ............................................ 29
Nephrotic Syndrome ...................... 140
Night sweats ........................ 22, 56, 65
Obstructive Airways Disease ........... 55
Oedema ....... 63, 91, 95, 115, 139, 165
peripheral ............ 22, 24, 126, 163
pulmonary ......... 24, 120, 121, 166
Onchocerca volvolus ............. 114, 115
Onychomycosis ............................. 179
Ophthalmia neonatorum ................ 143
Oral rehydration solution (ORS) ...... 90
Osteomalacia ................................... 99
Otitis externa.................................. 194
Otitis media ................ 49, 82, 156, 194
Pediculosis..................................... 183
Pertussis ........................................ 133
Photophobia................... 115, 125, 189
Pinworm ......................................... 102
Pityriasis
alba ......................................... 181
versicolor................................. 181
Placenta
accreta ...................................... 168
praevia ...................................... 167
Plasmodium
falciparum ....... 119, 120, 121, 122
260
malariae........................... 119, 120
ovale........................ 119, 120, 121
vivax ........................ 119, 120, 121
Pleural effusion .................. 24, 66, 126
Pneumonia ................................. 49, 51
Post-Exposure-Prophylaxis (PEP) 135,
159
Pott’s disease................................... 67
Pregnancy .............................. 155, 162
ectopic ............................. 152, 164
Protein-Energy-Malnutrition ............. 95
Proteinuria...... 139, 140, 163, 165, 166
Pruritus 102, 107, 115, 170, 173, 180,
183
Pterygium ....................................... 190
Pyrexia ........ 27, 39, 131,195, 197, 206
Rabies ............................................ 134
Rapid diagnostic test (RTD) ........... 121
Rash 108, 111, 115, 125, 128, 131,
145
allergic ..................................... 170
chronic..................................... 170
maculo-papular 125, 127, 128, 170
nappy....................................... 180
non-allergic.............................. 170
Recrudescence .............................. 120
Rehydration................................ 47, 90
Respiratory rate.......................... 50, 61
Respiratory tract infection ................ 49
Rheumatic fever ..................... 173, 197
Rhinitis ........................................... 196
Rickets ............................................. 98
Ringworm ....................................... 178
River blindness............................... 115
Roundworm.......................See Ascaris
Salmonella enteritis.......................... 79
Scabies .......................................... 181
Schistosomiasis28, 111, 138, 207, 219
Scrotal swelling ...................... 149, 153
Seizures .................... 38, 98, 165, 205
febrile............... 207, 209, 211, 212
generalized...... 206, 208, 211, 213
partial....... 206, 207, 209, 211, 213
Septicaemia ........... 109, 131, 157, 177
Index
Sexually transmitted diseases (STD)
.................................................. 142
Shigellosis........................................ 76
Shock .. 43, 47, 85, 126, 131, 164, 167,
184
anaphylaxis/ anaphylactic ......... 45
Sickle cell anaemia .......................... 35
Sinusitis ................................. 132, 196
Snake bite ........................................ 47
Sore throat ....................... 50, 197, 200
Splenomegaly .. 35, 112, 118, 120, 146
Sputum .................. 21, 50, 63, 65, 133
Staphylococcus aureus.................... 76
Stomatitis ....................................... 129
Stroke ............................ 203, 214, 219
Strongyloides stercoralis................ 108
Syphilis .......................................... 144
congenital................................ 146
primary .................................... 144
secondary ............................... 145
tertiary ..................................... 145
Tachypnoea.................. 51, 53, 63, 217
Taenia ..........................See Tapeworm
Tapeworm ...................................... 110
Tetanus .. 135, 164, 177, 178, 187, 222
Thalassaemia .................................. 34
Threadworm........................... 102, 108
Thrush....................... See Candidiasis
Tinea .............................See Ringworm
Tonsillitis ............................ 24, 82, 197
Toxic adenoma ...................... 199, 201
Trachoma....................................... 191
Transfusion ......See Blood Transfusion
Trauma ............................................ 43
Traveller’s diarrhoea ........................ 84
Treponema pallidum ...................... 144
Trichomoniasis ............................... 147
Trichuris trichiura............................ 103
Tuberculosis.... 65, 130, 141, 177, 207,
221
and AIDS ........................... 69, 156
extrapulmonary.......................... 66
in children .................................. 67
pulmonary............................ 56, 65
Typhoid fever ................ 28, 76, 80, 132
Ulcer .............................................. 117
corneal............................ 100, 129
gastric ....................................... 72
genital.............................144 - 150
tropical..................................... 177
Upper respiratory tract infection ....... 50
Urethritis................. 142, 144, 147, 150
Urinary Tract Infection (UTI)........... 138
Urticaria.................... 45, 108, 112, 170
Uterus
atonic....................................... 168
ruptured ................................... 167
Vaginal bleeding............. 164, 167, 168
Vaginal discharge........... 142, 148, 150
Vitamin A deficiency....... 100, 128, 129
Vitamin D deficiency......................... 98
Vomiting ........................................... 29
Vulvitis............................................ 102
Waterhouse-Friedrichsen’s-Syndrome
.................................................. 131
Weakness ........................................ 25
Whipworm ...................................... 103
Whooping cough ............................ 133
Widal test ......................................... 81
Wounds .......................................... 187
Wuchereria bancrofti ...................... 114
Xerophthalmia ................................ 100
261

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